Blakeway receives a lot of complaints. More than one in six people in England live in social rentals (compared to fewer than one in twenty in Australia). That’s about four million households, and Blakeway’s office is the place to go if they have a beef with their landlords, whether those institutions are not-for profit housing associations or local councils.

In 2022–23, the ombudsman made 6590 orders and recommendations designed to make things right for residents, including £1.1 million (A$2.1 million) in compensation. The call on Blakeway’s services is escalating at a phenomenal rate. “This financial year we’re up 91 per cent for formal investigations,” he tells me in an online interview. “We’re trending towards 10,000 formal investigations a year.”

Demand will grow even faster if the ombudsman is empowered to extend its services to another 4.4 million households in the private rental market, a change Blakeway would welcome. Most private tenants can’t currently access the free, independent, impartial redress his office provides, but a Renters Reform Bill could make his office the single venue for managing conflicts without the need to go to court.

Blakeway took up his role in 2019. His previous experience included serving as London’s deputy mayor for housing (when Boris Johnson was mayor) and as a director of the government housing agency, Homes England. Answering my questions, he is thoughtful and considered, and not prone to strong statements. In official verdicts on the failures of social housing providers, though, he is more direct.

Last July, for instance, he delivered a scathing judgement on the consistent failings of London’s largest social landlord, L&Q, which provides homes to a quarter of a million people. He found L&Q demonstrated little empathy in responding to residents’ complaints and in some cases was overtly dismissive, heavy-handed and lacking in respect. He ordered the organisation to pay £142,000 in compensation and apply 500 remedies including apologies and repairs. He has been equally critical of other big housing providers.

Resolving individual cases, though, only achieves so much. In a new report analysing complaints by vulnerable tenants, the ombudsman identifies patterns of landlord failure around attitudes, respect and rights. A fundamental reset is needed, he writes, and a royal commission into housing and health is the way to do it.

Remarkably, the ombudsman reaches back to the 1880s for inspiration. The Royal Commission on Housing of the Working Classes was, he writes, the “only inquiry of its kind to explore the relationship between housing and public health.” The commission was set up in 1884 by Conservative prime minister Lord Salisbury, who appointed himself — along with the Prince of Wales, former union leader Henry Broadhurst and several others — as one of its its members.

Salisbury believed that government-sponsored housing initiatives were vital to improve morality and health — a view criticised by the Manchester Guardian, among others, which described it as “state socialism pure and simple.” Despite the critics, the commission’s report produced “an explosion of transformative government-backed interventions, from council homes to garden suburbs.”

Britain’s subsequent tradition of regarding housing as a health issue saw significant housing developments led by health ministries. The ambitious 1919 Housing Act, for instance, which made housing a national responsibility, is generally called the Addison Act in reference to Dr Christopher Addison, the health minister who introduced it. After the second world war, Labour’s health minister Anuerin Bevan not only created the National Health Service but also, as minister responsible for housing, oversaw the construction of more than a million new dwellings in five years.

Public inquiries like Britain’s 1884 commission have also played an important role in Australia. Most notable is the Commonwealth Housing Commission initiated by postwar reconstruction minister Ben Chifley in 1943. Its report concluded that “a dwelling of good standard and equipment is not only the need, but the right of every citizen” and recommended that the national government “sponsor a government-financed housing programme.”

Up to that point, federal engagement in what was seen as a state issue had been limited. The commission provided the impetus for Commonwealth–state housing agreements over subsequent decades. While the scale of its ambition was never realised, more than 14 per cent of dwellings completed nationally between the end of the war and 1956 were built as public housing.

Richard Blakeway’s call for a royal commission “to reimagine the future of social housing” in the twenty-first century echoes similar calls in Australia. A 2021 report by the UNSW City Futures Research Centre argued for a royal commission to tackle “the scale and complexity” of the housing problem. More recently, the Centre for Equitable Housing urged the federal government to review its many and disparate housing-related outlays and bring them together in a single portfolio with clear objectives.

But both England and Australia are awash in reports from a succession of inquiries and housing research. Is the problem really a lack of data? Or is it a lack of political will?

One barrier in both countries is a basic disagreement about how to move forward. Proponents of the supply side argument say planning restrictions are limiting home building, driving up prices and rents. For them, the solution lies in looser planning and zoning rules to free up private development. Build more housing and rents will fall.

The contrary position is that market players have no incentive to build the type of homes that low-income earners can afford, especially when the tax system encourages investment in housing as an asset rather than a public good. The corollary of this critique is that government must reform taxation to reduce speculation and invest more public funds in low-rent housing.

These views are not mutually contradictory, and some action is happening on both fronts, but the supply-side argument seems to hold more sway with governments in both countries. In its 2019 election manifesto, Britain’s Conservative Party promised that it would lift residential construction to make sure 300,000 new homes are built annually in England. As parliament approaches the end of its term, completions are falling short of that figure, with about 234,000 new dwellings added to the housing stock in each of last two financial years. In a new initiative, secretary of state Michael Gove hopes to turbocharge development by compelling councils to speed up approvals for home building on former industrial or “brownfield” sites.

In Australia, the Albanese government aspires to deliver 1.2 million homes over five years, spurred by incentives to streamline planning and zoning rules at state and local levels. To hit this target developers would need to increase construction from 40,000 to 60,000 dwellings per quarter. Expert observers like Alan Kohler doubt the industry can build at such an unprecedented rate, particularly in current market conditions.

Investment in social housing has surged in Australia thanks to federal Labor’s Housing Australia Future Fund, or HAFF, and renewed state government initiatives. But after decades of neglect these projects won’t be enough to put roofs over the heads of Australians with unmet housing needs, including the 175,000 households on state and territory waiting lists for social housing.

In England, almost 1.3 million households are waiting for social housing, a dire statistic that manifests in clusters of tents pitched on the pavements of central London. In some parts of the city, more than one in ten children and teenagers live in temporary accommodation and are effectively homeless.

The Tory government says it has invested £11.5 billion since being elected to fund an affordable homes programme. It has just doubled a low-cost loan scheme from £3 billion to £6 billion to enable providers to build an extra 20,000 dwellings.

Historically, though, these numbers appear modest. In the thirty-five years after the second world war, local authorities and housing associations built 4.4 million dwellings; by 1981 almost a third of the English population lived in social housing. The share has halved in the decades since, not because demand has fallen but because there are far fewer socially provided homes. This month, the magazine Inside Housing reported that the number sold or demolished in England last year was nearly three times greater than the number completed.

An alliance of England’s largest housing associations has urged Michael Gove to invest £15 billion annually over the next decade to build 90,000 homes a year, a third of them in London. But having just lost two seats to Labour in recent by-elections and facing a wipe-out at the next election, prime minister Rishi Sunak is more inclined to woo voters by cutting taxes than by investing billions in public services.

Labour, meanwhile, is playing a cautious hand. It has promised the “biggest boost to affordable housing for a generation” but not the funding to match. Anxious to appear economically responsible, Labour has just scaled back the £28 billion green investment plan that was to be a central plank of its election manifesto. If Keir Starmer becomes prime minister, a big spend on housing looks unlikely.

As waiting lists for social housing grow, tenants lucky enough to have a subsidised roof over their heads can still find themselves in dire circumstances, reminiscent of the conditions that gave rise to Britain’s first housing inquiry in the 1880s.

In December 2020, in a case that’s become emblematic of the problem, two-year old Awaab Ishak died from a severe respiratory condition caused by persistent mould in the council home his family rented in Rochdale north of Manchester. Mould — one of the systemic problems identified in the ombudsman’s files — is also recognised as a major health threat to tenants in Australia.

Awaab’s parents had been complaining about the mould since 2017 but the local authority failed to act, saying the problem was caused by the family’s “lifestyle.” The ombudsman found many cases of social landlords adopting an accusatory approach rather than investigating other possible causes.

“Health and housing are closely aligned,” says Blakeway, “but the system doesn’t necessarily respond in that integrated way. There’s a real risk that complaints are treated in a kind of transactional way or become personalised. The risk is that they are treated in isolation, and you lose thematic qualities that complaints have, or you don’t do a root cause analysis.”

One housing worker told the ombudsman that tenants who challenge providers are “seen as troublemakers to be quashed.” This view gels with management’s dismissive response to Grenfell Tower residents who warned of urgent fire safety problems ahead of the 2017 inferno that killed seventy-two people.

Community outrage at Awaab’s death has prompted Michael Gove, the minister responsible for housing, to include Awaab’s Law in a new Social Housing Regulation Act. Landlords will now be required “to investigate and fix reported health hazards within specified timeframe.” But whether local authorities and housing associations have the resources to make quick repairs is another question.

More than one in ten dwellings in the social rented sector fail to live up to the Decent Homes Standard, the government benchmark for minimum housing conditions. And the English Housing Survey found that almost two-thirds of tenants who complain to their landlords are not happy with the response.

Tenants told the ombudsman that social landlords were quick to inform them about increased rents and service charges but poor in communicating about all other matters. Not surprisingly, this created a perception that social housing providers are “only interested in money, rather than the condition of their homes or the landlord/tenant relationship.”

An expert panel concluded that communication between tenants and their social landlords is hampered by the high turnover of stressed frontline housing workers. The panel’s Better Housing Review also found that tenants lack a strong voice and face-to-face contact with staff. Blakeway’s research confirms this finding: residents told his office that a simple knock at the door can help to maintain and improve the landlord/tenant relationship.

Funding shortfalls undoubtedly underpin these problems, and the housing crisis has been compounded by the perfect storm of Covid, Brexit, higher interest rates, labour shortages and supply chain bottlenecks. But Blakeway sees other factors at play too.

With around 2000 councils and not-for-profit associations providing social housing in England, a great variability is inevitable. Understandably, the providers’ focus has been on increasing housing supply, but Blakeway says that’s rarely balanced by consideration of what to do about ageing houses and flats in urgent need of upgrades.

He believes that providers hold to a fixed view that social housing is better than any alternative on offer to low-income tenants in the private rental market, which leads them to neglect residents’ needs.

Then there are long-term societal shifts. “If nothing else had changed,” says Blakeway, “the current population in social housing would have got older, above the national average.” That means more vulnerable residents, often concentrated coastal and rural areas.

Housing providers need to think about how to respond says Blakeway: “What does that mean for our services, for adaptations, for understanding of issues like dementia?”

This demographic transition has coincided with residents’ growing understanding of what they can demand under recent human rights, equality and care legislation. The ombudsman says housing providers haven’t done enough to modify residents’ homes in line with these laws. This has been exacerbated by cuts to other government supports. “Social landlords will very clearly say that they feel like they become a surrogate for social and health services,” says Blakeway. “That’s because they are one of the most visible and immediate touch points.”

To survive financially, housing associations are also compelled to become savvy commercial operators. Torus, for instance, claims not only to be the largest affordable housing provider in northwest England, but also “one of its biggest and fastest-growing developers and commercial contractors.” One Housing describes itself as “a group of complementary businesses driven by a clear social purpose, with a charitable housing association at its core.” Alongside social and affordable housing, it offers homes for private rent and private sale.

A lack of funding has forced providers to sweat their assets, a strategy the Better Housing Review panel said “is fast reaching its limits.” The expert panel worried that commercial considerations are distracting providers from their core purpose of providing “decent, safe homes for those who can’t afford the market.” It warns that mergers to achieve economies of scale run the risk of “working to KPIs more related to business efficiency” rather than “complex indicators such as tenant experience and satisfaction.”

Blakeway says consolidation in the social housing sector is driven by noble ambitions but notes organisations become more reliant on processes and systems as they grow. “If a resident doesn’t fit into the neat box or their issues are more complex than the system can cope with, that’s where we can see things being fractured and people through falling through gaps.”

In a 1942 pamphlet, Housing the Australian Nation, prominent Melbourne social reformers F. Oswald Barnett and W.O. Burt surveyed the appalling housing conditions experienced by Australia’s working classes and called for much greater government investment than previously imagined. Health was at the top of their concerns. Without better housing, they worried, efforts to improve health would be “seriously retarded.”

Today, the evidence is even more compelling. In England, the research group BRE calculates that it costs the National Health Service an annual £1.4 billion to treat people made sick by poor housing. Yet there are relatively inexpensive and cost-effective ways of dealing with the major risks: insulation to counter excessive cold, hard-wired smoke detectors to alert residents to fires, handrails to cut the risk of falls, ventilation to minimise mould and damp.

BRE estimates that spending to reduce these hazards would quickly pay for itself in savings to the NHS. In the private rental sector, the payback time would be between eight and nine years; in the social housing sector it would be twelve to thirteen years. (Social housing tales longer to generate a positive return because overcrowding is a major hazard and is more expensive to fix.)

The costs of poor housing go beyond healthcare to include such things as lost earnings for those who fall ill and those who must care for them. BRE calculates that total annual cost to society of leaving people living in poor housing is around £18.5 billion. As well as generating NHS savings, fixing housing hazards would create jobs, reduce energy costs, lower carbon emissions and improve property values.

Looked at this way, public investment in housing seems like a no-brainer, whether as a way of improving lives or as a prudent fiscal move. As the housing crisis deepens, the social and economic price we pay further outstrips the cost of action.

Australia is moving down a similar path to England where, in the 1980s, not-for-profit housing associations began taking on a role traditionally played by local government. Since 2006, the number of dwellings owned or managed by Australia’s not-for-profit providers has more than tripled, mostly thanks to stock being transfers from public housing authorities.

Funding from the HAFF and state programs to build new dwellings will increase the size of the not-for-profit sector and raise pressure on providers to consolidate to achieve efficiencies.But as in England, there is a risk that commercial imperatives could distract from the core business of providing decent homes for Australians priced out of the private market. This is more likely to happen in the absence of consistent public funding and clear government direction.

England has also had sixteen housing minsters in the fourteen years since the Conservatives took office. As the Better Housing Review panel commented, this revolving door means “a lack of consistent and strategic thinking and action.”  Yet the panel insists that government cannot outsources its obligations and must remain “fully accountable for the provision of decent housing nationally,” just as it remains responsible for health and education.

Like England, Australia lacks a coherent housing strategy and consultations to develop one have proved disappointing. For almost a decade, Coalition governments in Canberra insisted that housing was a state matter. While this has changed under Labor, we still have a housing minister with no housing department. As the Centre for Equitable Housing argues, the lack of a dedicated department or a consolidated housing budget statement makes impossible to properly shape or evaluate public policy.

Housing ombudsman Richard Blakeway thinks a royal commission could help solve England’s housing challenge and revive understanding of the close connection between decent homes and good health. Housing, he says, is a complex problem where solutions must be built on expertise, impartiality, independence and a long-term perspective — all things that a royal commission has the potential to deliver. Australia’s problems might be different, but they are just as serious. Perhaps here, too, it’s worth considering a public inquiry with the capacity to probe, publicise and make recommendations. •

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It’s little surprise that five of the six abstentions came from nuclear weapon states: the United States, China, Israel, Pakistan and India (joined, oddly, by South Sudan). But in a dismaying display of power politics, France and Britain voted with Russia and North Korea to oppose assistance to people and landscapes irradiated during decades of nuclear testing.

Diplomats representing Western powers are prone to talk about “the international community,” “the rules-based order” and “democratic versus authoritarian states.” But on this occasion the jargon was undercut by the willingness of London and Paris to line up alongside Moscow and Pyongyang to avoid responsibility for past actions and to limit reparations.

With the International Court of Justice debating genocide in Ukraine, Myanmar and Palestine and UN agencies seeking to defend international humanitarian law, the hypocrisy of major powers has been polarising international opinion. Developing nations are increasingly challenging an international order that sanctions official enemies, at the same time as absolving major powers of the responsibility to deal with their own breaches of international law.

Over the past three years, ambassadors Teburoro Tito of Kiribati and Akan Rakhmetullin of Kazakhstan have coordinated international consultations on how the nuclear assistance provisions of the Treaty on the Prohibition of Nuclear Weapons, or TPNW, should be implemented. Articles 6 and 7 of the treaty, which entered into force in January 2021, include unprecedented obligations on parties to the treaty to aid nuclear survivors and contribute to environmental remediation.

Kiribati and Kazakhstan might seem an unlikely couple, but they have bonded over a common twentieth-century legacy. Both nations’ lands, waters and peoples have been devastated by cold war nuclear testing, and in each case the responsible countries refuse to take responsibility. Britain and Russia have bonded, too, but in their case, they’re united in their refusal to assist their former colonies.

After conducting twelve atmospheric atomic tests in Australia in 1952–57 — at the Monte Bello Islands, Emu Field and Maralinga — Britain sought a new location for developing and testing more powerful hydrogen bombs. During Operation Grapple, the British military conducted nine atmospheric thermonuclear tests at Malden and Christmas (Kiritimati) islands in the Gilbert and Ellice Islands Colony, which is today part of the Republic of Kiribati.

Just as Britain chose the “vast empty spaces” of the South Australian desert and the isolated atolls of Kiribati for its tests, Moscow sought similar expanses within the Union of Soviet Socialist Republics. Over more than four decades, it held 456 nuclear tests in the Semipalatinsk region of Kazakhstan. The history of Soviet testing in the Central Asian republic and its radioactive legacies, spread across more than 18,000 square kilometres, has been documented by Kazakh scholar Togzhan Kassenova in her compelling 2022 book Atomic Steppe.

Once the TPNW was adopted, Kiribati and Kazakhstan led efforts to develop mechanisms for dealing with the health and environmental effects of radioactive fallout. After seeking technical advice from survivors, nuclear scientists and UN agencies, they developed a set of proposals for action and a UN resolution seeking international support.

Now adopted by the UN General Assembly, that resolution proposes bilateral, regional and multilateral action and the sharing of technical and scientific information about nuclear legacies, and “calls upon Member States in a position to do so to contribute technical and financial assistance as appropriate.” It requires UN secretary-general Antonio Guterres to seek members’ views and proposals about assistance to nuclear survivors and report back to the General Assembly.

Like most non-binding UN resolutions, this one is couched in the cautious diplomatic terminology required to forge a consensus among 193 UN member states. How then do the French and British governments justify their vote against assistance to nuclear survivors, a decision echoed by Vladimir Putin and Kim Jong-un?

When I put questions to France’s ambassador to the Pacific, Véronique Roger-Lacan, the French foreign affairs ministry replied, justifying its decision to stand with North Korea and Russia “because this resolution does not recognise the efforts already undertaken and because it aims to establish an international liability regime which ignores ongoing bilateral or national efforts, to which we are committed.”

According to the ministry, the French “fully” assume their “responsibilities and do everything we can to compensate all victims of nuclear tests, in accordance with the law of 5 January 2010 relating to the recognition and compensation of victims of French nuclear tests, modified in 2017. In this respect, France has in recent years strengthened its human and financial resources allocated to managing the consequences of the tests, including the identification and assistance of potential victims.”

It’s true that in 2010 France established the Comité d’Indemnisation des Victimes des Essais Nucléaires, or CIVEN, a commission to evaluate compensation claims from civilian and military personnel who staffed French nuclear test sites. But CIVEN’s significant flaws mean it is disingenuous to suggest that successive governments are “managing the consequences of the tests.”

President Emmanuel Macron’s refusal to respond fully to demands for assistance have been widely condemned by Mā’ohi political, church and community leaders in French Polynesia, where France conducted 193 nuclear tests from 1966 until as recently as 1996. They note, for example, that during its first five years of operation CIVEN approved only 2 per cent of claims submitted by personnel exposed to hazardous levels of ionising radiation at Moruroa and Fangataufa atolls.

Changes to the law since 2017 have improved the compensation process, but CIVEN still rejects more than half of all applications. Political and community leaders in French Polynesia continue to push for further reforms as well as an apology for the ongoing trauma caused by thirty years of testing.

In 2022 the French government created a special Mémoire des Hommes website dedicated to the Mā’ohi Nui nuclear testing program and began declassifying some relevant documents. But only archives relating to the Pacific Testing Centre are eligible for declassification — not those that cover France’s atmospheric and underground tests in Algeria between 1960 and 1965. France used its North African colony to conduct four atmospheric nuclear tests at Reggane and thirteen underground tests at In Eker in the Sahara desert, tests that continuing three years beyond Algerian independence in 1962 to give Paris time to build its testing bases in the South Pacific.

Indigenous survivors and researchers from the Nuclear Truth Project continue to call for better access to nuclear archives and the release of the documentary evidence required for compensation programs. They have also developed protocols to ensure any efforts for remediation and assistance are focused on redress for both historic and future harms from nuclear activities.

December’s UN resolution is just one step in a longer campaign to deal with the humanitarian impacts of nuclear weapons under the TPNW. Seventy countries have now ratified that treaty, and the nuclear weapon states are getting anxious.

The United States, France and Britain — the three states that tested nuclear weapons in Oceania — first tried to ignore the TPNW, but as the number of ratifications mounted, they began to actively oppose it. In our region, eleven Pacific island countries and territories have ratified or acceded to TPNW and the remaining colonial dependencies have also joined the call for assistance to nuclear survivors, even though they can’t sign the treaty.

In September last year the Assembly of French Polynesia unanimously passed a resolution in support of the TPNW. As ICAN France, the local affiliate of the International Campaign to Abolish the Nuclear Weapons, noted, “while French Polynesia cannot currently access the assistance and rehabilitation outlined in Articles 6 and 7 of the TPNW due to France’s non-ratification, it sends a resounding message in favour of the treaty to Paris.”

President Moetai Brotherson of French Polynesia says the Assembly resolution sends an important message to Paris. “It’s not legally binding, so that’s probably one of the reasons they don’t really care about it,” Brotherson told me in November. “But it has a symbolic value that is very strong. For us, it’s only natural that we have this kind of position taken at the parliament. It’s a message we want to send to the world — that nuclear weapons are dangerous and we can destroy this planet if we are not cautious about it.”

In Australia, Kiribati, Marshall Islands and French Polynesia, Indigenous communities affected by nuclear testing want the weapons states to provide funds for independent, comprehensive radiological surveys of nuclear test sites and surrounding communities. They also want the nuclear powers to monitor, secure and remove nuclear wastes on a scale and standard comparable to the clean-up of domestic nuclear sites in their home territory.

As they ended their twentieth-century test programs, the Western powers used the Pacific Ocean as a dumping ground. A 2017 French government report on ocean dumping of nuclear waste admits that 2580 tonnes of nuclear waste in concrete drums was dumped in the ocean at site Oscar off Moruroa atoll in the eight years from 1974. Seventy-six tonnes of untreated radioactive waste had already been submerged at the nearby November site between 1972 and 1975.

ICAN France has also documented significant amounts of nuclear waste buried in the Sahara desert after France’s seventeen nuclear tests in Algeria, even though the French government still refuses to communicate details of the waste and landfill locations to Algerian authorities.

British nuclear test sites in the Monte Bello Islands and South Australian desert are also scarred with the radioactive legacies of atmospheric tests and the hundreds of experiments — including burning uranium and plutonium — conducted on the land of the Anangu people. The nuclear threat to these sacrifice zones is not over. Last year, Barngarla traditional owners won a long battle to protect their country and storylines from the proposed establishment of a radioactive waste on their land near Kimba in South Australia.

France’s answers to my questions about why it joined Russia and North Korea to vote against the Kiribati/Kazakhstan resolution might have been less than satisfactory, but British high commissions in the Pacific declined to respond at all.

Unlike France and the United States, Britain doesn’t have a compensation commission for survivors of nuclear testing. In fact, Britain has a shameful record of nuclear secrecy: in 2018, the National Archives withdrew public access to key files about British nuclear testing in Oceania.

Over more than thirty years, British, Australian, NZ and Fijian military veterans who served at British nuclear test sites in Kiribati and Australia have unsuccessfully lodged a series of cases and appeals before British courts and the European Court of Human Rights. They have sought damages under civil law for the illnesses they attribute to their service at nuclear test sites. Britain’s defence ministry has consistently opposed these claims, unfailingly appealing against lower court rulings that assisted veterans.

A fatal problem for the veterans is that they lack documentary evidence of rates of radioactive exposure for military personnel — evidence still buried in the British archives. Last month, the UK Daily Mirror reported how successive governments have maintained the cover-up, with government agencies refusing to release relevant data. “In 2018, the UK Ministry of Defence claimed it ‘had no information’ about blood testing during the nuclear trials,” the newspaper reported. “Last year the Atomic Weapons Establishment, an MoD agency, admitted it holds up to 5000 files, including a list of 150 specific documents mentioning blood and urine tests taken during the weapons program.”

At a time of warfare in Europe and the Middle East, the actions of these nuclear weapon states highlight their hypocrisy. As civilians are massacred in Ukraine and Gaza, developing nations are mobilising through the UN General Assembly, the International Court of Justice and the International Criminal Court to end a culture of impunity for states that declare themselves democratic. •

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Its reforms to Medicare have the potential to transform the operation of a system that, despite its reputation for good health outcomes, is creaking if not yet collapsing. Much more healthcare would be delivered through general practitioners and much less through hospitals and emergency departments. Fee-for-service remuneration for doctors, long a barrier to reform, would be diluted by alternative funding models based on the needs of individual patients.

In turn, GP practices would take on nurses, nurse practitioners, physiotherapists and other professionals, enabling doctors to focus on the more complex cases for which their training qualifies them. Continuity of care would be given greater emphasis, particularly for the rapidly rising number of patients with chronic conditions.

That is the ambition. The announcements in the May budget were a first cautious step down this path. Given the history of false starts in health reform in Australia, the challenge will be implementation, and that means overcoming resistance from the medical lobbies. As health minister Mark Butler put it in May, stakeholders in health “have sharp elbows and loud voices and they don’t always agree.”

In the same speech Butler characterised the Medicare scheme introduced by the Hawke government as a great system for the 1980s but wholly inadequate forty years later. That makes a change from the traditional political boast that Australia has one of the best, if not the best, health systems in the world.

Butler said that chronic conditions were now the leading cause of illness, disability and death in Australia. More than 13,000 patients went to hospital ten or more times a year. Rather than sporadic visits to the doctor, he argued, they need a coordinated team of health professionals — GPs, allied health workers, nurses and specialists, among others.

The statistics are confronting. Chronic conditions such as heart disease, diabetes and mental illness comprised 12 per cent of GP case loads in 1962, had more than doubled to 27 per cent by 2015 and are now close to 50 per cent. A fee-for-service system that results in average GP consultations of fifteen minutes is unsuited to such a reality, as are regulations that discourage the involvement of other health professionals.

Butler argued that general practice was in its worst state since the introduction of Medicare, with a fall from 50 per cent to 14 per cent in medical graduates choosing it as a career. Rebuilding general practice is the government’s highest priority, he added, including reversing the substantial decline in bulk-billing.

The biggest gripe among doctors has been the refusal of successive governments to increase Medicare rebates, which remained frozen for a good part of the past decade. Despite that, profit margins for GP practices, which have in many cases expanded from small or solo enterprises into large businesses, have remained at about 35 to 38 per cent of turnover over the last decade, according to the Melbourne Institute. And despite the shortages of GPs in rural areas, OECD figures for 2020 showed Australia with 123 GPs per 100,000 people compared with an OECD average of eighty-eight. One reason for this difference is the dominance of GPs in Australia, compared with a greater reliance on other health professionals overseas.

May’s federal budget funded a small general increase in rebates but also included a more targeted approach, tripling bulk-billing incentives for consultations involving families with children under sixteen, pensioners and Commonwealth concession card holders. That increase translates to an extra $13.80 for a standard consultation in metropolitan areas up to an extra $26.50 in very remote areas. It applies from 1 November, so its effectiveness remains to be seen.

Meanwhile, bulk-billing rates have been falling and the Australian Medical Association has recently recommended higher fees for patients. In some areas outside the big cities the challenge is finding any GP, let alone one who bulk-bills.

Steve Robson, president of the Australian Medical Association, is offering no guarantees on the bulk-billing incentive. “My sense is that it will probably stabilise things,” he tells me. “In the longer term the question is if we are to make care available, equitable and affordable for the patients who are most vulnerable, there are going to need to be more strategies in place than bulk-billing incentives.” Elizabeth Deveny, chief executive of the Consumers Health Forum, is slightly more hopeful. Though the incentive is no silver bullet, she believes bulk-billing rates will rise.

The government is promising fifty-eight urgent-care clinics as alternatives to overburdened and costly hospital emergency departments. Extra funding will help bring what is still an antiquated system of digital health records into the modern age with the aim of ensuring ready access to patient information.

Perhaps of greatest longer-run significance are the other measures announced. The budget provides funding for more nurses, including those working in primary care with GPs, and offers incentives for practices to employ them and other health professionals such as physiotherapists. Again, the idea is to free doctors from tasks that others can perform — signing off on repeat prescriptions, for example, which currently involves four million GP visits a year — enabling them to concentrate on more complex services, including treating chronic conditions. The Grattan Institute estimates that every ten GPs in Australia are supported by three nurses or other clinicians, compared with ten in Britain.

Extra funding is promised for consultations of sixty minutes or more, which are typically required for chronic conditions. Rebates will rise for nurse practitioners, the highly qualified professionals who play a major role in many countries but have been marginalised in Australia.

Under a new MyMedicare program, the government is encouraging patients to enrol with general practices — a system widely used overseas — to provide continuity of care and funding based on patient needs. As Butler said in his May speech: “MyMedicare is the foundation upon which we can build a range of blended funding models to better serve the needs of patients that fall through the cracks of our 1980s Medicare.” It will extend to multidisciplinary care for chronic diseases and frequent hospital users.

The Grattan Institute’s blended funding model would provide multidisciplinary medical practices with 70 per cent of their existing funding through “capitation payments” — payments per patient rather than per consultation — and 30 per cent through fee-for-service. (In other words, the fee-for-service component would be 30 per cent of the current rate.) Capitation is calculated according to the health, risk and socioeconomic profile of patients who enrol with a practice. Practices would be encouraged to opt into this model with a $25,000 grant from the government.

Blended funding, together with many of the government’s other announcements are not so much new as recycled ideas or extensions of existing programs. Stretching back to 1997, several rounds of coordinated care trials have tested multidisciplinary care for mainly complex cases. But they were not continued. Blended funding models were tried in different programs between 2011 and 2014 and between 2017 and 2021.

The Grattan Institute study, which noted that health has seen “more pilots than Qantas,” found that many trials suffered from design problems and insufficient implementation time. It also reported concerns about “stakeholder capture” — a polite way of describing doctors defending their patches.

Creating multidisciplinary teams of health professionals and more alternatives to expensive hospital care harks all the way back to the community health centres established by the Whitlam government in the early 1970s, for which funding was cut by subsequent governments.

“Other countries have reformed general practice and their rates of avoidable hospital visits for chronic disease are falling,” says Grattan. “Australia has spent twenty-five years on a merry-go-round of tests and trials that have not changed the system and our rates are holding steady. We are spending more and more on hospitals, while neglecting general practice: the best place to tackle chronic disease.”

The OECD also stresses this point in its latest economic review of Australia. Noting the relatively high cost of hospital treatment, it points out that hospital admission rates in Australia for diseases that can be treated by GPs are close to the highest in the developed world.

If the history of healthcare in Australia shows anything it’s that reforms are hard-won. When the recently departed Bill Hayden, as health minister in the Whitlam government, moved to bring Australia into line with every developed country apart from the United Sates by introducing a universal national health system, doctors’ groups ran a campaign against “nationalised medicine” that would make Donald Trump proud. One article in an AMA journal compared the threatened “enslavement” of the medical profession to that of Jews in Germany, and a poster featured the slogan “Heil wHITLAm.” Maliciously false rumours were spread that Hayden had been a corrupt policeman and was mentally ill.

Although the Fraser government systematically dismantled Hayden’s Medibank it was resurrected as Medicare by the Hawke government in 1984 — although not without another nasty campaign by doctors spreading false rumours about health minister Neal Blewett, who successfully sued for undisclosed damages.

The Coalition kept campaigning against the scheme until shadow health minister Michael Wooldridge persuaded John Howard to support it in the 1996 election because it had become too popular to oppose. That didn’t stop the Howard government from chipping away and undermining it.

Despite their periods of paranoia, doctors have generally done well out of Medicare, notwithstanding funding cuts under Coalition governments. Not only are they no longer campaigning against Medicare, but they are voicing support for the Butler reforms. The minister’s decision to include representatives of all the main health professions on his taskforce no doubt helped, with its report paving the way for the subsequent announcements. It gave doctors a stake in the plans and allowed them to claim some of the credit.

As AMA president Steve Robson put it, “something unexpected happened” following the AMA’s campaign to modernise Medicare. “Government listened,” he added, and went on to recite a list of budget initiatives.

Nicole Higgins, president of the Royal Australian College of General Practitioners, was positively effusive, welcoming the budget as “a game changer… For the first time in decades we have a government that’s committed to strengthening Medicare and general practice care.”

Former federal health department head Stephen Duckett, until recently health program director at the Grattan Institute and now an honorary professor at Melbourne University, puts this new mood into perspective. “Up until very recently the medical profession was opposed to any hint of any move whatsoever away from fee-for-service,” he says. “What has been announced so far is not going to fix primary care itself but what it is doing is signalling the direction of change. It is like putting a little bit of sand in the oyster: eventually a pearl will emerge.”

In between his work as an obstetrician and gynaecologist and as AMA president, Robson has been studying for a master’s degree in health economics, which he says has fired his interest in and concern about the economic sustainability of the health system. Reminded of the AMA’s reputation as the Builders Labourers Federation of the medical profession, he laughingly responds, “I think that award has gone to the Pharmacy Guild” — a reference to that organisation’s over-the-top campaign against the government’s introduction of sixty-day prescriptions.

But the heavy artillery remains ready to be deployed. Or, as Robson puts it, “There is a time to hold a hand and a time to slap it. At the moment we want to make it very clear that we are very keen to work with the government on sustainability and at the same time to make sure we are respected for the care we provide.”

Given the increased emphasis Butler is placing on the primary care provided by GPs, that approach makes sense for the doctors’ groups. Robson’s interpretation of blended funding under MyMedicare is that extra money for enrolled patients will be provided on top of existing fee-for-service payments — in other words quite different from the Grattan model of patient-based payments substituting in part for fee-for-service. Duckett suspects the Grattan formula, which follows overseas practice, may be too big a political hurdle for the government. Peter Breadon, Grattan’s health program director, says restricting patient budgets to a small part of total funding would be a missed opportunity for meaningful reform.

Given the doctors’ sensitivity, the government is treading warily, not responding to my request for clarification about how blended funding will work. It doesn’t use the word “capitation” in the context of blended funding because it raises red flags. “What we want to get completely away from is the UK system of capitation,” says Robson, a view echoed by the RACGP’s Higgins. Importantly, capitation-based patient enrolment is compulsory in the British system but would not be here. But Breadon argues that the real problem with Britain’s National Health Service is the severe austerity under which it operates, with long waiting lists and chronic workforce shortages. It’s not the British funding model that’s the problem, he says, “it’s the funding quantum.”

Nor, despite the increases in Medicare rebates and the bulk-billing incentive, is Robson making any concessions on rebates. To cover costs, he argues, they need to double from an average $40 per GP visit. As to whether the government is amenable to further increases: “They are not going to have a lot of choice if they want to make the health system sustainable.” So expect some future slapping.

Plenty of problems remain to be tackled. While bulk-billing rates for GPs are falling, they remain higher than for other health professionals. In 2021–22 the rates for allied health services were an average of 51 per cent compared with 88 per cent for GPs.

And in that year nearly half a million Australians decided against seeing a specialist because they couldn’t afford it. On average, about 50 per cent of initial appointments with a dermatologist, urologist, obstetrician or ophthalmologist cost more than double the $90 Medicare schedule fee. As with allied health care, those most affected were the ones who needed the services most, namely the sickest and the poorest.

The Commonwealth Fund, a US-based health research body that conducts international surveys, found that 28 per cent of Australians reported out-of-pocket expenses equivalent to more than US$1000 a year in 2020, exceeded only by Switzerland and the United States among eleven higher-income countries. Thirty-two per cent skipped dental care, which is not covered by Medicare, because of cost, second only to the United States.

Fee-for-service’s continuing predominance encourages overservicing. According to a 2015 OECD study, knee-replacement surgery in Australia occurred at almost twice the rate of France and almost five times the rate of Israel. Antibiotics were prescribed at twice the rate of the Netherlands.

Despite large government subsidies, private health insurance remains a bad deal for many patients, with premiums rising faster than inflation and significant out-of-pocket costs for private hospital treatment. Nor does the evidence show that this form of insurance has done anything substantial to fulfil its claimed objective of taking pressure off public hospitals, mainly because private practice is much more lucrative for doctors, as well as much more expensive for patients.

Prevention remains the Cinderella of the health system, neglected and funded at lower rates than in most OECD countries. Isolated examples of success, including one of the lowest rates of smoking in the developed world, haven’t brought forth similar efforts in areas crying out for attention, such as Australia’s high rate of obesity. The Abbott government abolished the Preventive Health Agency and only now is an interim body planned while legislation is brought forward for an independent Centre for Disease Control, expected to be running by early 2025. Its focus will be on preparing for future pandemics, but it also will have a broader prevention brief.

Then there’s the overall financing of health, which remains a muddle of overlapping Commonwealth and state responsibilities. The states run hospitals but they are jointly funded by the Commonwealth; when problems arise, they blame the Commonwealth and demand more money. Many aged care residents spend excessive and very expensive periods in hospitals because the Commonwealth funds aged care and lacks the incentive to move people to more suitable and much cheaper facilities. Thirty or more years of reports, recommendations and attempts at reform — most recently under the Rudd government — have failed to bring meaningful change.

National cabinet agreed in August to devote a special meeting before the end of the year to this and other issues in health. But there is still no word on a date or an agenda for this meeting.

For Labor, the longer-term question is whether caution will overcome ambition. On this, the last word belongs to Ian Hickie, professor of psychiatry at Sydney University’s Brain and Mind Centre:

Back in 2008 I had a book contract to describe the obvious failings in Australian healthcare. It was planned to challenge the national myth that our system was “exceptional,” literally “best in the world.” I didn’t persist as prime minister Kevin Rudd was promising sweeping national reforms and there was genuine community enthusiasm for a major revamp of Medicare.

How I wish I had persisted! The glaring structural faults in the system have simply grown wider and deeper over the last fifteen years. Now the federal health minister Mark Butler is saying in public what his predecessors would only discuss in private. Our 1980s-style Medicare no longer delivers a fair, equitable or sustainable system… The challenge for the Albanese government is not to get stuck in the arguments about how best to re-design the Titanic. •

The post Medicare’s forty-year update appeared first on Inside Story.

In a nutshell, that is the case advanced in The Age of Scientific Wellness. It’s a new science book looking at the world of AI and genomics in medicine. Throughout, the authors — two highly qualified and very well-respected scientists with decades of experience behind them — weave a tale in which what we call medicine is irretrievably broken and our health will only improve once their futuristic paradigm emerges from the ruins.

As the story goes, what we currently call healthcare is, in fact, “sickcare” or “deathcare.” Right now, most treatment is provided to people when they are already suffering from disease’s symptoms, but that’s backwards. Instead, the authors propose, we should use the vast wealth of data that people now generate about their own health to better understand their long-term risks, and figure out how to identify problems with health long before they happen. We can then prevent these conditions, thus saving us all a great deal of suffering.

This brave new world will be built on emerging healthcare technologies. The authors focus particularly on genomics, microbiomics — the study of the bacteria and other micro-organisms that live in and on our bodies — and brain health. The book wends its way through a tapestry of possibilities, discussing how we can improve cognitive outcomes and capitalise on the vast promise that AI holds for improving our lives.

The Age of Scientific Wellness starts out strongly, but ultimately much of it rings a bit hollow. The authors focus relentlessly on the positives, but to those of us who remember IBM Watson, an enormous investment into medical AI that crashed and burned over the course of a decade, it’s harder to be optimistic. The authors talk about a wonderful future where we all have access to endless data about ourselves, but they also acknowledge that they already tried to form a company based on this promise, Arivale, and it fell apart in 2019.

There’s not much evidence in the book to back up its relentless optimism. From the first chapters, the focus of wellness and personalised medicine is clearly defined as common chronic diseases — diabetes, heart disease, chronic obstructive pulmonary disease — but the success stories included in the book simply don’t match the hype.

We’re introduced to Lynn, who was experiencing the early symptoms of Hashimoto’s thyroiditis and was diagnosed a bit earlier than expected because of the huge gamut of tests Arivale ran on her. Max, another patient, was experiencing health problems that were traced back to extremely low vitamin B12 levels. Another woman, Beth, was diagnosed with colon cancer because of anomalous blood cortisol results.

These are not grand stories of a novel way of medicine. They are boring, everyday stories of how medicine works already. Despite the heady rhetoric of the book about finding people long before they become unwell, virtually all the practical examples deal with illness the traditional medical system would usually pick up anyway.

The authors blame much of the inertia within healthcare on profit incentives, saying things like “trillions of dollars have already been spent for infrastructure and disease strategies that are expected to pay off in the long run… if that changes, the equation changes.” That reads oddly coming from the former owners of a company, Arivale, that charged people thousands of dollars a year for testing and treatment that the book’s descriptions suggest were not proven to have any specific benefit.

This is a well-known problem with precision medicine, and something the book silently struggles with right the way through. We have been capable for years of identifying the people most likely to experience a gamut of diseases, but we have yet to be able to change their fate. A famous saying in medicine is “treat the patient, not the x-ray”: this book seems focused on sorting out minor inconsistencies in various tests rather than on healthcare improvements that will make a difference in people’s lives.

Everyone who has prediabetes is at a pretty high risk of developing diabetes in the near future, something we’ve known since at least the 1980s, but the treatments we have to prevent that transition are still fairly slim — essentially, we recommend diet, exercise and sometimes one or two medications. The main theme of The Age of Scientific Wellness — that identifying illness risk early can completely prevent negative disease states — is missing a crucial step.

There’s also not a great deal of evidence that personalising treatments makes them more effective. Trials of personalised diets have shown, at best, minimal benefits when compared with generic advice. One of the main take-homes from the book — that you should train your brain to reduce your long-term risk of cognitive issues — has very weak evidence behind it and may not improve your outlook.

As a visionary tract, The Age of Scientific Wellness ultimately doesn’t feel convincing enough. The authors are genuine authorities and they lay out their arguments methodically, but I was left sceptical about their vision of the future. We’ve had access to most of this technology for more than a decade. It’s already long past the time when any of this could revolutionise the world overnight.

The book is also not one I’d recommend for those looking for an easy read. Phrases like “these data will allow us to identify data-informed multimodal intervention strategies for personalised care and disease reversal” are pretty common throughout. It often feels like a book written for other scientists working in non-healthcare disciplines rather than for a wider audience.

If you have an advanced degree in a scientific discipline and are looking for a well-written review of some of the more hopeful treatment paradigms that people are spending enormous sums of money on these days, The Age of Scientific Wellness is worth picking up. And the chapters on Alzheimer’s are a harrowing and worthwhile read for anyone with a family member suffering from the condition.

For me, though, the combination of extreme complexity and overwhelming — at times inappropriate — optimism ultimately felt just a little bit misleading. If it had been written in 2013, this book would be visionary, but in 2023 it feels a bit more like a sales pitch for something that has already been and gone. •

The Age of Scientific Wellness: Why the Future of Medicine Is Personalized, Predictive, Data-Rich, and in Your Hands
By Leroy Hood and Nathan Price | Harvard University Press | $55.95 | 352 pages

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Embarrassed by her escape, William decided to pay Bee a weekly allowance in the hope she would keep as far away from him and the family as possible. This she mostly did, but she was unable to curb her disruptive and sometimes violent public behaviour. She was constantly being arrested, charged and fined, and was jailed when she could not pay the fines; many times she was forced back into asylums. This was the pattern for almost the rest of the life of the woman widely known as  a Sydney bohemian.

During and after the second world war Sydney’s acute housing shortage forced Bee to sleep rough. It is a common myth that she chose homelessness. “No one chooses to be homeless,” notes Rose Ellis, in Bee Miles, the first major biography of her subject. When Bee could no longer afford to rent a room but her allowance meant the city’s social services couldn’t help her, she declared herself a “tenant of the city.” Writes Ellis: Sydney’s “public heart became home, its streets and steps her bed.”

Bee would wake at 5am, hook her blankets to her belt and make her way from wherever she had been sleeping to Mason’s Café in Elizabeth Street, opposite Central Station. She breakfasted there on steak and eggs every morning for nearly twenty years. Afterwards she would go to Dobson’s Turkish Bathhouse where she was given a regular free timeslot to have a bath and wash her hair and clothes. The myth says that Bee was “dirty,” but it wasn’t so. She loved a long, hot bath.

Bee’s working day as a “roving reciter” (Ellis’s words) then began. Passing a delicatessen where she received a free bottle of milk and a barrow where she received a piece of fruit, she would catch a bus from Eddy Avenue to some destination, Watson’s Bay perhaps, where she would offer recitals of poetry and prose for money. Her rates varied from sixpence to three shillings, and Shakespeare was her favourite. To advertise this service she wore a sandwich board.

Back in the city she would perform through the afternoon at a regular spot, such as the steps at the Mitchell Library where there was a regular flow of students. She used to enjoy visits to its reading room until she was banned for smoking. She might end her day with a visit to a friend, not that she had many, or a bookshop or cinema. She dined at 5pm, always curried tongue and peas, and chose her place to sleep for the night, which could be a cave at Rushcutters Bay, under a shed in the Domain, on the steps of St James church opposite Hyde Park Barracks, or in the bandstand at Belmore Park.

After years of being moved on and jumped on, having her blankets and shoes kicked away, and sometimes even being urinated on by the police, Bee finally accepted refuge from Father John Hope (uncle of Manning Clark), rector of Christ Church St Laurence. She slept on the floor of the laundry in the clergy house.

Bee Miles was always on the move. She loved speed — and risk.  As a young woman she became known as “mad Bee Miles” for jumping on and off moving trains on her way from the family home in Wahroonga to the University of Sydney. Her university career lasted only a year and it was said (another myth, of course) that her mind was “turned” by too much study.

She would cling to the bumper bars or footboards of cars, or climb right into a car or taxi and order the driver to drive on. She refused to pay on public transport and conductors learned that it was often wiser not to demand a fare, fearful of the scenes she could cause. Some of her most violent confrontations came when taxi drivers, judging her dishevelled appearance, refused to take her as a paying customer. She suffered several serious assaults this way, the driver-perpetrators never charged.

Prodigiously researched (it began as a PhD), Ellis’s life of Bee Miles unfolds elegantly, uninterrupted by personal perspectives or anecdotes of Ellis’s own. She shares nothing about the relationship she must have developed with her subject (surely every biographer has one). If she essayed a night sleeping in the bandstand in Belmore Park, she doesn’t say. She’s not that kind of biographer.

Her book begins serenely enough. We discover a small girl seated at a piano in a room with a vaulted ceiling and long stained-glass windows overlooking a sprawling garden. The girl is Beatrice Miles and she is practising under the careful but kindly gaze of her grandmother, Ellen Cordner-Miles, a celebrated contralto in Sydney in the 1870s. The afternoon light fades but the girl plays on in the otherwise silent house.

Ellen’s son William Miles, Bee’s father, had taken on various family business enterprises and of these Peapes & Co., a men’s clothing store in George Street, was the most successful. William and his wife Maria had five children. Bee (she insisted on “Bee” and not “Bea”) was born in 1902.

William was a man of contradictions, as famous for his business acumen as for his political radicalism. A devotee of the rationalist and free-thought movements, he raised his children as atheists and taught them the rationalist dictum to reject all forms of “arbitrary” authority. During the first world war he took to a speaker’s box on the Domain to rail against the proposed introduction of conscription, and he instructed his three daughters to wear “No” badges at their school, Abbotsleigh College. Bee relished the ensuing controversy, though her sisters did not.

William might have encouraged Bee’s agile mind but he didn’t expect her to reject his own authority. Her adolescent years were torrid. “Family friction is a battle fought daily,” Ellis observes. “Superficial wounds heal quickly in readiness for the next confrontation. But parental rejection leaves scars that are deep and enduring.”

Fifty years later Bee recalled that her father loved her until she reached the age of fourteen, after which he hated her, angered by her “wilful” nature and jealous of her superior intellect. And yet she also claimed that her mother became jealous of the close relationship between father and daughter, which was more than close, Bee said, it was incestuous. Bee believed that William feared that his wife would go to the police or tell a doctor.

Further trouble came when, at seventeen, Bee contracted encephalitis lethargica, known as “sleeping sickness.” She was with her mother buying gloves at Farmer’s department store one day when she fell asleep at the counter and could not be woken. She had fallen victim to a pandemic, brought to Australia by a returning Anzac, that caused 500,000 deaths in Europe and Australia.

Encephalitis lethargica mainly targeted young people, leaving survivors like Bee with lifelong side effects. Unusually, she escaped the Parkinsonism that afflicted other sufferers, but sensitivity to light (in later years she often wore a sunshade), obesity (she put on weight massively in her forties) and, most significantly, her exhibitionism and her addiction to movement: all were probably the after-effects of encephalitis lethargica.

Here then is the “untold story” of the title of this book, and an ah ha! moment for readers who have heard of or still remember Bee Miles. Ellis treats the subject of Bee’s illness very carefully. Early on she gives enough information about the disease and its effects for the reader to carry forward into the rest of the book because it explains so much about Bee.

But encephalitis lethargica was not the only thing to shape Bee. What with adolescent trauma and her own questing mind, she may never have settled for the life of a North Shore lady anyway. Ellis wants us to know about the joys and freedoms Bee experienced, as well as the pain and loneliness.

By the time she returns to Bee’s illness in the penultimate chapter of the book I was ready and eager to know more. Bee became ill in 1920 and nearly died. Ellis has worked through thirty-six years’ worth of Bee’s medical case notes and finds that although encephalitis lethargica was mentioned many times, specifically or in passing, her doctors condemned Bee through the lens of their own morality. She was “wilful,” “restless,” “impulsive,” “childish,” “arrogant,” “impudent” and “tearful.”

All of this, as well as her attention-seeking behaviour and love of speed and movement, was consistent with well-documented observations of post-encephalitis syndrome. But no one fully explored the link, even though the syndrome was being identified in Australian medical literature at the time. Doctors chose instead to believe her father, who may also have been her abuser, who claimed that Bee had always been “wilful” and lacked “respect for authority” — even though he himself had actively taught her to reject arbitrary authority.

Was Bee herself aware of the probable impact of her illness? Apparently so. In front of a magistrate in 1932 she shouted at her solicitor to “shut up” when he alluded to the effects of sleeping sickness. Many of us would find relief in a formal diagnosis (“at least I’m not actually mad”), but Bee never did. Refusing to be labelled, she rationalised her behaviour into her own view of herself.

She built this view through her public performances and the many press interviews she gave over four decades. She also wrote prolifically and longed to be published. Some of her short travelogues did appear in regional newspapers, but her longer work, including accounts of her incarceration in the 1920s and the massive journeys she made to northern Australia in the 1930s, never found a publisher. Ellis quotes Bee’s own words extensively, however, and thus ensures that she can be known on her own terms and not just as the construct of a male gaze captured in court records and medical case notes.

At sixty-two, after a life of fiercely resisting authority and convention, Bee finally accepted a place in a Catholic-run nursing home, where she died in 1973. A journalist for the Daily Telegraph who visited her in her cave near Rushcutters Bay in 1948 had listed Bee’s fifteen “rules for living.” They included avoiding covetousness, being content with what you have, singing when you are happy, sleeping when it’s dark, and living “toughly, dangerously, excitingly, exhilaratingly and simply.” •

Bee Miles: Australia’s Famous Bohemian Rebel, and the Untold Story Behind the Legend
By Rose Ellis | Allen & Unwin | $34.99 | 336 pages

The post Living toughly appeared first on Inside Story.

Resources minister Madeleine King announced that all activities at the site will end immediately, apologised for the “uncertainty” experienced by Kimba residents and acknowledged her regret for the “profound distress” experienced by Traditional Owners — the Barngarla people — during the decision-making process.

King’s announcement came less than a month after the Barngarla Determination Aboriginal Corporation’s campaign against the facility culminated in a breakthrough Federal Court verdict. Justice Natalie Charlesworth ruled that the decision to store Australia’s nuclear waste at Napandee was subject to “apprehended bias” and should thus be set aside. Her decision has been labelled a “king hit” for plans to dispose of Australia’s low- to intermediate-level nuclear waste.

But while many assume that the ruling rested on native title (an issue that was certainly discussed), the minister wanted to make clear that the “question raised in this case was about a decision-making process, not a claim of native title.” In reality, the judgement was a comment on consecutive Australian governments’ inability to take public anxieties about nuclear waste seriously, a tendency stretching back decades.

As Justice Charlesworth detailed, the evidence led her to conclude that former resources minister Keith Pitt had “already made up his mind about the selection of Napandee as the site” ahead of its formal determination. By making statements “to the effect that the Australian Government had made a commitment or promise to the people of Kimba that a radioactive waste facility would be situated at Napandee,” Pitt was judged to have shown apprehended bias — that is, his mind was “foreclosed” to the possibility that the post-nomination consultation would change the outcome.

Justice Charlesworth found that Pitt also displayed a “dismissive attitude to its key opponents, the Barngarla people.” Describing the judgement as the conclusion of a “David and Goliath” battle, the Barngarla Determination Aboriginal Corporation’s chair, Jason Bilney, reflected on the outcome in light of truth-telling: “It’s about listening to the First Nations people, and here we are today and we prevailed and we won.”

Napandee was a latecomer to the process of deciding where Australia’s nuclear waste would be stored. The first round of applications had resulted in just one suitable site: Wallerberdina Station, near Hawker, in South Australia’s Flinders Ranges. Seeking further options in late 2016, resources minister Matt Canavan approved an amendment to the nomination guidelines to allow private landholders to nominate their own properties for consideration. Early the following year, the federal government received several new sites for consideration; one of them was Napandee, a 160-hectare property put forward by owner Jeff Baldock.

With these new sites in contention, efforts began in Hawker and Kimba to gauge local support for the facility. Several ballots conducted as part of the consultation process returned a slim majority vote against hosting Australia’s nuclear waste in Hawker (48–52) and a majority for hosting it in Kimba (62–38). Both communities were divided, and in both cases the Traditional Owners argued they had been “locked out” of voting and not adequately consulted. Once Napandee was selected as the final location in 2020, the Barngarla committed to having the decision reversed.

Justice Charlesworth’s judgement might be a welcome one for the Traditional Owners but it by no means marks the end of the wider debate over the storage of Australia’s nuclear waste. After all, Australians have been here before and will undoubtedly find themselves here again.

If it feels as though the issue of radioactive waste has been in the news for a very long time, that’s because it has. For decades, politicians, experts and the public have debated the ins and outs of radioactive waste storage and disposal in Australia. As the debate rages on, the nation’s nuclear waste mounts.

Australia’s existing waste consists mainly of low-level radioactive waste products and contaminated materials used in medicine, industry and scientific research: contaminated PPE, for example, and unused radiopharmaceuticals and contaminated gowns and bedlinen. The nation’s radioactive waste burden is partly the consequence of saving countless lives: in 2022 alone, 300,000 nuclear medicine diagnostic exams were claimed on Medicare, each of them producing both low- and intermediate-level nuclear waste.

Regardless of radioactive materials’ positive uses, the mental leap from nuclear waste to barrels of toxic sludge, ballooning mushroom clouds and radiation sickness shouldn’t be dismissed. Uncertainty about radioactivity’s association with cancer and other serious health concerns, its impact on the environment and the contradictory way it appears to be handled and approached by authorities induce unease. Rather than treat these anxieties as baseless, decision-makers need to face them head-on and deal with them seriously.

This was exactly the advice given to the Keating government in the No Time to Waste report released by the Senate Select Committee on the Dangers of Radioactive Waste in 1996. The committee found that the rules and regulations governing nuclear waste storage were not only difficult to understand but were also inadequately enforced. The rules themselves hadn’t kept up with shifting international standards and appeared to operate differently from state to state. Coming after a nuclear waste spill at Port Augusta in 1991, these conclusions would only have increased public concern.

The more recent case of a radioactive capsule lost in remote Western Australia is a good reminder of why such concern prevails. Australians were told not to be concerned by the misplaced 8mm diameter capsule, but — in the same breath — were “urged” not to touch it. Chief health officer Andrew Robertson, who chairs the Radiological Council of Western Australia, warned that coming into contact with the tiny capsule “could cause radiation burns or severe illness.”

Once it was found, though, the public health risk associated with the capsule was reported as having been extremely remote. The contradictory messages, and the lapses of security with which they were associated, caused understandable apprehension.

But accidents like these don’t just fuel anxiety. They also fuel discussion of the need for a national remedy to the risks posed by the decentralised handling of potentially dangerous radioactive materials. At present, Australia’s nuclear waste is housed at over one hundred sites across the country — some of them in populous areas — including hospitals, universities, mines and the Lucas Heights reactor in Sydney. Proposals for national repositories to centralise these storages extend back at least to 1998.

The proposal most like the one successfully opposed last month came in 1998, when prime minister John Howard took up the Senate committee’s recommendation of two years earlier that the government begin seeking a site for a national, well-regulated waste repository. Opposition flowed thick and fast, laced with fears that placing the waste in the desert would merely put it “out of sight, out of mind.”

Ever conscious of the radioactive legacies of British nuclear testing at Maralinga and Emu Field, and also aware of the waste generated at the large-scale Olympic Dam mine, many South Australians resented the suggestion that theirs would become the nuclear waste state. But it wasn’t the state’s nuclear past that determined the repository’s fate; it was the government’s determination to stick to a “decide and defend” model of site location, as Griffith University’s Ian Lowe recently described it.

Cabinet papers released earlier this year detail the Howard government’s plans to defy opposition from South Australians. They reveal cabinet’s commitment to defending the government’s choice of site through “the compulsory acquisition of… native title rights and interests in the area” and the overriding of “any South Australian legislation which seeks to prohibit the establishment of the national repository.”

South Australia’s Rann government brought a Federal Court case against the Commonwealth in 2004, arguing that attempts to compulsorily acquire land in South Australia for nuclear waste storage were unlawful. As it did last month, the Federal Court ruled in favour of the applicants.

Howard subsequently announced the government’s decision to “abandon” the repository because of a “failure of the states and territories to cooperate with the Australian Government in finding a national solution for the safe and secure disposal of low level radioactive waste.” What might have been interpreted by Howard as a failure by the states to cooperate with his government would have been interpreted by affected communities as the federal government’s failure to cooperate with them. Precisely the same accusation was levelled by the Barngarla.

In light of this month’s ruling, and echoing Howard, Minister King last week reaffirmed her government’s commitment to safely storing and disposing of Australia’s nuclear waste. Looking ahead, though, AUKUS and Australia’s acquisition of nuclear submarines will profoundly affect this commitment. And only last week Nationals leader David Littleproud reaffirmed the Coalition’s view that Australia should go nuclear.

Larger-scale nuclear pursuits — including nuclear submarines — would undoubtedly complicate Australia’s nuclear waste disposal. To date, Australian governments, Coalition and Labor, have been unable to secure widespread public support for a national storage or disposal facility for low- to intermediate-level radioactive waste. Yet the AUKUS security pact makes Australia responsible for the storage of high-level waste produced by its submarine fleet.

Despite assurances that this won’t be a problem until at least the 2050s, the prospect is well worth considering in light of the Federal Court’s ruling. This judgement, like those that came before it, demonstrates that nuclear waste storage and disposal in Australia isn’t necessarily an issue of technical ability (though this remains up for debate); rather, it requires governments to both obtain community consent and allay public concerns.

As King made clear, a national waste facility “requires broad community support.” This doesn’t mean simply obtaining the support of ratepayers or property owners — it means the whole community. And while this is undoubtedly an immense task, if the recent and earlier judgements teach us anything, it is that an issue like this won’t be resolved until communities’ voices are heard and apprehensions adequately considered. •

The post No time to waste appeared first on Inside Story.

In retrospect, what were we thinking? Did we really believe private companies would put serving the public above profit? That companies wouldn’t take advantage of light-touch regulation? That their insistence on commercial confidentiality wasn’t designed to protect their operations from scrutiny?

Which leads to another question: is our whole approach to social services systemically flawed?

Mark Considine, a professor of political science at Melbourne University with decades of experience in examining social programs, thinks so. His recent book The Careless State brings together what we tend to see as separate problems — problems that add up to an indictment of the privatisation and deregulation of Australian social policy — and provides some pointers to how we could do better.

Social services reform became an extension of the enthusiasm for financial deregulation, free markets and privatisation that swept the world during the 1980s and was taken up by the Hawke and Keating governments in Australia. Why not try market-based reforms in new areas, even though they were outside the traditional market economy? Lumbering, inefficient bureaucracies and the community service model went out of fashion; competition, choice and entrepreneurial flair were all the rage.

Efficient markets are driven by price competition, but in the new social service markets prices were set by a single purchaser of the services, which was the government. But governments lost touch with how services were provided and often found themselves reduced to mopping up and repairing when things went awry.

Not-for-profit providers shrank, unable to compete with the often ruthless cost-cutting and understaffing of their profit-making rivals. Clients, particularly the vulnerable, often fell prey to lack of information or misleading information. The absence of real alternatives made choice illusory.

Another result was that the quality of services deteriorated. “If money can be made by providing a terrible service, that is what a market will allow,” writes Considine. Serious fraud and rorting of the rules, costing billions of dollars, were evident in all the market-driven services he examined.

So what now? The timing may just be right for a serious reassessment. A change of government in Canberra and the searing experience of robodebt might provide the impetus for change.

One of those who commented on a draft of Considine’s book was Glyn Davis, who was vice-chancellor of Melbourne University. Davis has since been appointed by Anthony Albanese to head the Department of the Prime Minister and Cabinet, and wants to pursue the issues Considine identified.

Not surprisingly, The Careless State has struck a chord with non-government providers and charities, though not so much with for-profit enterprises. It also has attracted international attention: Considine has been invited as the keynote speaker at the annual Social Outcomes conference in Oxford next month.

Considine says that Britain saw a similar shift to market-based services, starting with the Blair government. But it was never as gung-ho in its approach and is already well on the way to a reconsideration. He recalls a British bureaucrat remarking that his counterparts in Canberra “were always more Catholic than the Pope.” Denmark, Israel and the Netherlands have already moved away from a free-wheeling market approach towards a more mixed model of public coordination and governance.

Australian politicians are starting to take notice as well. As chair of the select parliamentary committee on employment services, Victorian federal Labor MP Julian Hill kept the attention of his audience of employment providers with a provocative speech last October. “Over two decades of evidence raises legitimate questions about the impact of marketisation,” he said, “and there are a growing number of informed sceptics deeply concerned that competition and choice has failed and will continue to fail the most vulnerable consumers.”

The Albanese government made some changes to employment services last year. Among them was that those jobseekers considered the easiest to return to work are no longer assigned to employment agencies, for whom they were easy earners, but are instead referred to a digital service. The existing system remains for two-thirds of unemployed people, however, including an estimated 500,000 who have been on benefits for more than a year — a figure that has barely changed despite a substantial fall in overall unemployment.

The government’s changes prompted Hill to ask his audience: “Will you respond to the greater flexibility in the system and upfront investment by investing in people? Or will we see more ‘creaming and parking,’ as has plagued the privatised system for twenty years, underinvesting in those who need the most help?” Hill was referring to the fact that more money could be made by “creaming” — moving the easiest clients quickly into jobs — while “parking” those with greater needs but fewer prospects of employment.

Those hoping Hill’s views may be tempered by Liberals on the committee could be disappointed. Russell Broadbent, a Victorian Liberal MP with a long record of hewing an independent path, is the committee’s deputy chair. He praises Hill’s bipartisan approach, is impressed with the critique developed by Considine (who has given evidence to the inquiry), and is concerned the present system plays into the hands of those who argue that “everyone who hasn’t got a job is a slacker. That is just not true — most have multiple barriers to entry into the workforce.”

Broadbent also makes broader criticisms of the market-based social services. “How come private aged-care providers drive exceptionally beautiful cars? It’s not because they’re living on the breadline: it’s because they have taken their million dollars out and say to the managers ‘there’s the money that’s left — make it work.’” He hastens to add that not everyone deserves to be tarred with the same brush.

When Paul Keating’s government shook up employment services in 1995 it went further than most developed nations. The Commonwealth Employment Service was retained but forced to compete with private job agencies. The unemployed would be able to shop around for the best service, and quality would be assured by competition between providers.

As the rhetoric of the time put it, the government would be steering, not rowing. It would set the policies but not run the services. The shift fitted nicely with another fashion — the drive for smaller government.

Capturing the mood of the moment, Keating favourably compared the new market with the previous public “monolith.” But Considine quotes another reason Keating gave for the reform: “One of the things you have always got to do when you think about social reform in Australia is to make it Tory-proof… you have got to hermetically seal them so they can’t get their nasty little right-wing fingernails under them and tear them away.” In short, Labor adopted a policy it thought the Liberals could only agree with.

That’s not quite how it worked out. The Howard government did retain the changes but reshaped them in its own, harsher image. It increased the proportion of employment services transferred from the CES to private providers from 30 per cent to 50 per cent and whittled it away further in subsequent years. Then it closed the government body down completely, leaving the whole field to non-government providers.

It also removed the “mutual” in the mutual obligation policy introduced by the Keating reforms, cutting spending on the training programs that the government had provided for long-term unemployed and introducing Work for the Dole as a condition for retaining benefits. This pandered to the populist notion mentioned by Broadbent — the unemployed as “slackers” or “bludgers” (see also robodebt). Although it has been shown to do almost nothing to help people find real jobs, Work for the Dole has been retained by the Albanese government.

Against a background of rapidly increasing demand for social services, the same arguments for choice and competition influenced new policies in aged care, childcare, vocational training and later the NDIS. In the first two decades of this century, aged care spending rose from 2.8 per cent to 3.5 per cent of the total federal budget. For childcare the increase was from 0.77 per cent to 1.53 per cent; for employment services, including income support and job assistance, from 3.3 per cent to 4.5 per cent.

In the name of “contestability,” for-profit firms were allowed to offer their services alongside not-for-profit companies and community organisations. “A church agency with a history of 100 years of philanthropic work to the unemployed would be considered no better and no worse than an entrepreneur seeking to make a profit from the same social services market,” writes Considine.

Even the most respected charities were sucked into the vortex of ruthless competition. In 2005, the Salvation Army in Victoria was forced to repay more than $9 million for fraudulently upgrading unemployed clients to a “highly disadvantaged” classification so that they attracted much higher fees. Staggeringly, a 2012 audit found that only 42 per cent of job-finding fees charged by providers were genuine.

Private providers also sprang up like mushrooms when vocational education and training was progressively deregulated and privatised, starting under the Hawke government in the 1980s and eventually enfeebling the states’ TAFE systems. The reforms culminated in what Considine describes as “the most spectacular frauds yet seen in any social program… With extraordinary profits to be made, the system was deluged with providers targeting the most disadvantaged customers with courses that had little value and sign-up incentives that made it appear they were getting their program for free.”

Students had choices but insufficient information to make them meaningful, particularly if they were international students. In theory, they could switch to other providers if they were unhappy about the quality of the training they were receiving. In practice, enrolment and course fees created effective barriers. The education and training provided by some firms were so poor that childcare firms refused to employ their graduates.

Childcare itself has also performed poorly. Government subsidies for the rapidly expanding sector often feed almost directly into higher fees and bigger profits. A 2021 study found that an Australian couple on average wages spent 16 per cent of their income on childcare, compared with 3 per cent in South Korea, 4 per cent in Sweden and 5 per cent in Iceland.

“In effect childcare providers lift fees according to what the consumers will bear, with politicians then pressured to reduce some of the cost this generates for families,” Considine writes. He adds that childcare has also become a real estate business, with a bias towards the suburbs with the best prospects for capital gains.

The shortcomings in another market-driven sector, aged care, were tragically thrust into the spotlight during Covid, particularly in Victoria. The aged care royal commission’s scathing report labelled the neglect of clients, including physical and sexual abuse by staff, a “disgrace” that “should be a source of national shame.” Cutting costs on meals, typically described in promotional material as “home cooked”, meant many in care were malnourished.

The pandemic also highlighted how the best-quality care was being provided in government-run homes, where there were far fewer deaths. Eighteen reviews of aged care over twenty-four years led Considine to the conclusion that governance of the sector was “catastrophically weak.”

Substantial increases in funding disguise the fact that the system has not kept up with the increased demands of an ageing population. Considine estimates a 40 per cent reduction in spending per client over twenty-five years, coinciding with the steady shift from a community service to a market model.

Regulation has increased but is often ineffective. Large-scale gaming of the system is evident, with the proportion of nursing home residents classified as needing complex health care — which attracts higher funding — increasing from 12.7 per cent to 53 per cent over the decade to 2019.

Inspections of facilities do occur, but always with plenty of notice. “You knew at least a week ahead,” says one executive quoted in the book. Remarkably, the industry has prevailed in its strong objections to unannounced inspections. The Australian Aged Care Quality and Safety Agency is compromised by operating inside the health department, which makes the policy decisions in aged care.

For providers, the incentives are perverse: rather than rewarding them for higher standards, the system encourages them to cut costs to generate higher demand and bigger profits. Staff are underpaid and undertrained, which also means they lack the authority to advocate on behalf of clients.

Considine believes the aged care royal commission has not gone anywhere near far enough in its recommendations. “There’s a lot of regulation raining down from above but not much internal self-management and learning,” he says. “We haven’t actually laid out the basis of a transparent care strategy. I think there is still a very high likelihood, even with more trained personnel, that the management of some of these residential places could be behaving in a really unsatisfactory fashion.”

The National Disability Insurance Scheme, the largest reform in social policy since Medicare, is admirable in its charter to give everyone with a serious disability the right and the means to obtain the assistance they choose and need. What sets it apart from the other social programs Considine examined is the role of two intermediaries — local area and support coordinators — who help clients draw up a plan and implement it, making for more effective choice.

But the NDIS still incorporates some of the same problems Considine identified in the other programs. It relies on a market for services, with the aim of using competition between providers to achieve greater efficiency. But the services offered have not always been adequate in terms of quality and availability.

The NDIS example raises another weakness in market-based social programs — what Considine calls the “black box.” Instead of the government prescribing how services are delivered, it allows providers to offer services according to their own “secret recipe,” in the interests of innovation, competition and efficiency.

Considine gives the example of a provider who suggests weekly appointments when monthly appointments are adequate; clients then ask for higher funding to cover this. The government’s National Disability Insurance Agency, or NDIA, may see costs going up but be unable to act effectively against over-servicing because it doesn’t know enough about the services provided or has limited ability to act.

The Quality and Safeguards Commission is supposed to be the NDIS cop but it is seldom on the beat. In 2020, when it reported on the death of a person whose carer was charged with manslaughter, it had received more than 8000 complaints over two years but banned only one provider.

Considine identifies other inequities in the NDIS, with better-off or more articulate people or their families able to argue for better care plans. And the government’s arm’s-length approach creates the ever-present danger of fraud, as it has done in other choice-based social systems.

Last year, the NDIA reported that eighteen people had been charged since 2020 over alleged fraud against the NDIS totalling up to $14 million. At the same time, the head of the Australian Criminal Intelligence Commission, Michael Phelan, estimated that as much as a fifth of the $30 billion annual spending on the NDIS had been misappropriated. His agency had uncovered fake NDIS clients, systematically inflated invoices, payments for services never provided, and a network of professionals helping criminals exploit the scheme.

The picture Considine paints is not unremittingly bleak. Workplace health and safety has moved in the opposite direction, from a private insurance market approach to something closer to a public–private partnership, with greater government — in this case state government — involvement and control. The cost of the schemes Considine examined in New South Wales and Victoria rose and fell at different times but were ultimately brought under control alongside improvements in health and safety.

Employers are still able to choose their insurers, but uniform standards were set and operators are required to be more transparent, encouraging a “learn from the best” culture, as opposed to the black box approach. And workplace inspections occur without prior notice.

One other area Considine identifies as an outlier is maternal and child health, which is still a public service delivered by state governments and local councils at centres staffed by specialist nurses. The service is available to everyone; to the degree choice is provided, it involves public rather than private providers. The service has a high reputation, says Considine, and offers few opportunities for fraud or “creaming.”

While the Albanese government seems prepared to listen to critics of the present system, and while at least some people believe it is open to persuasion, its risk-averse approach to change raises questions about its willingness to embrace wholesale reform.

Some signs are less than encouraging. The government’s draft national care and support economy strategy talks, among other things, about “functioning markets, sustainable funding and… productivity gains.” In its response, the Australian Council of Social Service urges the government to look at better options, including alternatives to markets, given the “litany of systemic failures and inadequacies with markets in social services.” Anglicare argues that the government should take back the control and operation of employment services.

Considine believes the markets-and-choices model has been exhausted. The pendulum needs to swing back towards empowering the clients and staff of the services — “from choice to voice,” as he puts it.

A culture of improvement and innovation must come from within. Vulnerable people in particular should have access to specialists who advocate for their needs. The black boxes within which providers guard their business models have to be replaced with more transparency. Governments need to take responsibility for services as well as setting the standards.

Is that enough? “I don’t have the view that nationalising these services is necessary,” says Considine. “In most of these social services, where the government has been working with community organisations, it works well. There are some private organisations in childcare and aged care and parts of the NDIS who are credible.

“I don’t have a problem with a mixed economy. I have a problem with running a social service as if is a market. You need to run it as a public service because that is what it is.” •

The post “You need to run it as a public service because that is what it is” appeared first on Inside Story.

Twitter in particular has witnessed some egregiously bad behaviour by “Covid Zero” advocates seeking public vengeance for what they paint as a malign conspiracy to deny the hidden truths of Covid-19 — its transmission via the airborne route, its prevention via public masking and lockdowns, the threat of Long Covid and disability, and the need to aim for elimination rather than mitigation.

I was genuinely shocked to see a senior researcher, a full professor, seeking to humiliate a PhD student with whom they disagreed by naming and shaming his supervisors, implying guilt by association. I was staggered to see a medical doctor describe people at an airport not wearing masks as “oldies, fatties and crumblies.”

It sickens me to watch as one prominent ventilation advocate launches abusive screeds targeting doctors working on the Covid frontline. I feel sorry for clinicians abused because they don’t wear the level of PPE favoured by Covid Zero advocates.

If the case for Covid Zero is strong, it shouldn’t be necessary to try to publicly shame people who disagree with it. These tactics call into question the strength of the arguments that underpin this campaign. They highlight the non-rational drivers of these positions: the traumatic affects that are being given full voice on social media platforms.

As a queer person working in HIV, I’ve lived through this before, and our present situation gives me a powerful sense of pandemic déjà vu. I can’t overstate the importance of excising these practices from socially acceptable norms of conduct, while undertaking the kind of cultural production that helps us understand where they are coming from — the traumatic affects, experiences and practices to which pandemics give rise.

This can be an exceptionally slow process, prone to sparking “history wars” and paroxysms of public rage over seemingly benign topics. The queer community fought all-in battles over the changing meanings of HIV. First, as the HIV response became professionalised rather than resting in the hands of activists and volunteers. Then, following the widespread uptake of effective antiretroviral treatments, as the meaning of HIV changed from a death sentence to a lifelong, manageable condition. Finally, as the advent of preventive medication meant condoms were no longer the only game in town.

On each occasion, community figureheads took up purist and punitive positions and strategies. The damage caused to vulnerable members of the community was incalculable; it was toxic shaming at its absolute worst. It wasn’t enough to win the argument; it wasn’t even a debate in any rational sense — chosen scapegoats had to be obliterated, if not from this earth then, at least, from public view; they were shamed into silence. Each time this happened, necessary debates over HIV prevention policy and programming were set back years, if not decades.

Traumatic affect was clearly playing out in those conflicts. In 1995, at the peak of the AIDS crisis in the United States, 50,000 people were dying each year in communities that made up, on contemporary estimates, about 1.5 per cent of the adult population. That’s 1.2 per cent of that community’s population dying each year — for reference, that’s four times the mortality rate of Covid-19 in the mainstream US population.

These dry calculations only thinly approximate the human, social, relational and emotional impacts of the epidemic. It falls to cultural products like film and television and books to account for the incalculable costs.

One film that does this especially well is Robin Campillo’s 120 BPM (2018) about ACT UP Paris. (It is available to rent for $5 on Apple TV.) The film opens in a lecture theatre, in a loud and only loosely organised collective meeting, as newcomer Nathan (Arnaud Valois) watches activists planning their next protest and, while this happens, checks out cute firebrand Sean (Nahuel Pérez Biscayart). The film tells the story of the collective, their protests against recalcitrant governments and drug companies, and the emerging relationship between Nathan and Sean, which ends in scenes of unbearable tenderness.

The film interweaves the moments of tragedy and agency that were simultaneously embodied in the queer community’s response to HIV and AIDS, and powerfully evokes its protagonists’ overwhelming perception of government and the public: “They don’t give a fuck about us.” (A perception that is no doubt familiar to the many people left behind as Australia transitions into a Covid-Normal existence.) It highlights the diversity of people and groups engaged in the battle against HIV, rather than presenting cisgender, white, educated middle-class men as the heroes of the epidemic response.

Right now, we are missing two things.

First is the community infrastructure that, in the HIV epidemic, enabled affected communities to respond effectively with prevention programs, and to care for and support people living and dying with HIV and AIDS. We have a Heart Foundation, Cancer Councils, AIDS Councils, PWDA, but no organisation dedicated to representing the people most affected by Covid-19. This gap harms people who are vulnerable to severe illness and people fighting for recognition, treatment, services and research on Long Covid. In the absence of a representative body we are only hearing the loudest voices, not voices informed by the diverse needs and experiences of this community.

Second, we urgently need an investment in public storytelling that can help us understand Covid-19 as a mass traumatising experience. There is scholarly debate over whether Covid-19 lockdowns had lasting impacts on people’s mental health, often judged using simplistic measures of depression and anxiety included in longitudinal survey research. But the whole point about trauma is that symptoms often take time to emerge, and they are often quite indirect — it’s not immediately obvious where they are coming from and what has triggered them.

Trauma also has effects that play out at the collective level, reshaping how a group of people sees itself and organises its everyday life. Public narrative is one of the most powerful therapeutic interventions for grappling with and resolving individual and collective traumatic experience.

For this to happen we need the discourse over Covid-19 to shift gears. Public rage and pathos-filled personal narratives can pay off; both are ways of building an audience. But it is possible to get hooked on rage, stuck in the black-and-white, blame-and-shame mindset it produces. There is little possibility of processing the traumatic experience when you are spending hours each day marinating your brain in other people’s digitally mediated stress hormones. It is time for the merchants of rage to take a breath or take a seat. •

The post Pandemic déjà vu appeared first on Inside Story.

The reclassification would encourage smokers to discuss with their GP “the best way to give up smoking, such as using other products including patches or sprays,” the government argued. If e-cigarettes were still required, the GP would write a prescription.

It looked promising on paper, but the plan failed to deliver the desired result, a fact that even Nationals leader David Littleproud now admits.

The failure had complex causes, including shortcomings in state and federal enforcement of the laws that regulate importing, wholesaling and retailing of e-cigarettes at both federal and state/territory levels. Complicating these efforts is the fact that only laboratory testing can detect whether vaping products contain nicotine, which means that importers and retailers can misleadingly label vaping products as nicotine-free to avoid scrutiny.

But there was another unanticipated obstacle to controlling e-cigarettes: the emergence of a welter of online nicotine-prescribing services offering vaping products outside traditional general practices, often with little or no contact with doctors.

These new businesses are being fuelled by a combination of unfortunate timing and poor policy design. The reclassification of nicotine as a prescription-only drug coincided with the accelerated adoption of telehealth consultations during the pandemic; more importantly, though, the new Medical Benefits Scheme number for these consultations didn’t require patients to have an existing relationship with the prescribing doctor — unlike most other telehealth services.

The new prescribing services are a long way from the GP oversight envisaged by Hunt when he introduced this restriction. They don’t provide any healthcare services other than nicotine prescribing. Their doctors don’t have an ongoing relationship with the patient. Worse, in some cases patients have no direct contact at all with a doctor; they simply fill out an online form requesting a prescription, which is then sent to them via text or email. The websites’ claim that these requests are “reviewed” by a doctor is impossible to verify

Many of these prescribing services operate outside Medicare and typically charge less than a Medicare-funded consultation for a prescription. Some also sell vaping products (or refer consumers to an affiliated supplier) and then rebate the prescribing fee against the purchase of vaping products.

Not surprisingly, GPs and health experts have raised a range of safety and quality concerns about the growth of these services. Among those to speak out is Chris Moy, a South Australian GP and former national vice-president of the Australian Medical Association, who is concerned that consultations provided by these services are disconnected from the type of holistic patient care offered by traditional general practice. Because the nicotine-prescribing doctor has no access to a patient’s history, he says, continuity of care can break down. Patients could develop side effects without the knowledge of their usual GP.

The vice-president of the Royal Australian College of General Practitioners, Bruce Willett, says that while the dangers of vaping aren’t yet fully understood, the increasing use of e-cigarettes, particularly among young people and school-age children, is deeply concerning. He believes that online prescription services come with “numerous risks” and enable nicotine products to be more easily obtained by vulnerable consumers.

“My message to anyone thinking about using these services to get a prescription for nicotine e-cigarettes is to think again — and book an appointment with your GP instead,” he adds.

Another concern being raised about these new services is the conflict of interest that could arise if prescribers have a financial interest in selling vaping products to their patients or if businesses selling vaping products have a financial relationship with a prescriber.

The prescribing and selling of medicines are deliberately kept separate in our health system to remove any possibility of doctors’ decisions being influenced by financial interests. But the law doesn’t prohibit all financial relationships between prescribers and dispensers. While the terms of the Community Pharmacy Agreement prohibit doctors from owning a pharmacy, for example, pharmacies can employ doctors perfectly legally.

That means pharmacies can set up online prescribing services employing doctors to provide electronic nicotine prescriptions that encourage consumers to fill these prescriptions at the pharmacy — by linking the prescription directly to the pharmacy, for example, or by rebating the cost of the consultation against purchases.

Pharmacies are also allowed to produce or import their own vaping products and can promote these to consumers without violating the Therapeutic Goods Advertising Code — for example, by listing them above other products when directing consumers to their website to fill their prescriptions.

Regardless of legality, Chris Moy is concerned about the potential for conflicts of interest if pharmacies or other business that sell vaping products have a financial relationship with nicotine-prescribing services. “A doctor’s sole interest should be in the health of their patient,” he says, “but the situation becomes muddied if the doctor makes a profit from selling a product they prescribe, or if they are employed by a business which does so.” Willett also stresses the need for providers to make any conflict of interest — “anything that could affect, or could be perceived to affect, patient care” — clear to patients.

Measuring exactly how many nicotine prescriptions are being provided by standalone services is impossible. The Therapeutic Goods Administration’s register of authorised nicotine prescribers lists 1635 Australia-wide, of which around fifty-five prescribe only online. But the TGA doesn’t collect information about the level and type of interactions the prescribing doctors have with their patients. Medicare keeps records of the number of nicotine prescriptions issued via telehealth but doesn’t record the proportion written in a traditional general practice setting.

Given the significant health and economic harms caused by smoking, it is clearly important to make quitting tools accessible to smokers. Recent evidence suggests that e-cigarettes can be a useful quitting tool for some smokers (although researchers’ views differ about their effectiveness). But the potential benefits of making e-cigarettes available to smokers need to be balanced against the risks of non-smokers (particularly children and young people) accessing these products.

The new standalone prescribing services make it easier for consumers to access e-cigarettes for purposes other than quitting smoking. They raise concerns about conflicts of interests between prescribers, dispensers and retailers, and create ethically questionable opportunities for healthcare professionals to profit from the spread of vaping in the Australian population.

Health minister Mark Butler’s recently announced plan to ban personal importation of nicotine is a step forward — albeit a belated one — in tackling the public health threat of vaping. But unless it is part of a comprehensive strategy that also regulates how nicotine is prescribed online, it seems likely to divert demand from overseas providers to these services, further entrenching this business model within the Australian health system. If the government is serious about reducing the rate of vaping in Australia, it needs to look carefully at this growing sector and the role government policy plays in its spread throughout the Australian community. •

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The self-help genre is diverse, ranging from the high-minded to the profane. Some books explore the latest research, bending the scientific branch so that readers can pluck a few peer-reviewed insights. Some give us simple advice, selling in direct proportion to how closely it counsels us to do what we already secretly want, such as not to give a f*ck about anything. All are supremely confident that they hold the key to improving our lives.

The Good Life and How to Live It falls closer to the first end of the spectrum. The evidence on which it rests is unquestionably the largest and arguably the best of any book of life advice. Authors Robert Waldinger and Marc Schulz are director and associate director of the Harvard Study of Adult Development, a research project that has been running since 1938, and their book reflects on its many decades of findings.

The study is an odd hybrid, composed of 268 sophomores from the male-only Harvard College of the early 1940s; 456 inner-city Boston boys from the same period; and more than 1300 of their descendants. Study participants were followed intensively throughout their lives, with an extraordinarily high retention rate by the standards of longitudinal research.

The focus of assessment reflected the changing preoccupations of the times, from skull measurements, handwriting analysis and questions about being ticklish in the early days, to genotyping and MRI scans today. Throughout the four score and almost seven years, though, psychological assessments have been central.

A study whose original 700-odd participants were all male, all white, a mix of gilded youth — John F. Kennedy was a participant — and tenement dwellers, and deliberately selected for being promising rather than representative, might seem an unlikely source of knowledge about normal human ageing. But one of the compensating virtues of the Harvard Study is that despite its demographic restrictions it revealed the diversity and unpredictability of paths through life. In spite of their advantages, many of the Harvard collegians were failures, especially when considering outcomes beyond conventional accomplishments, and their life trajectories ranged from tragic downturns to hopeful redemptions and everything in between.

The Harvard Study was designed as an inquiry into adult development and ageing, but The Good Life reframes it, not always convincingly but with good market awareness, as an investigation of happiness. Its central message is simple. As George Vaillant, the study’s director from 1972 to 2004, once put it, “the key to healthy aging is relationships, relationships, relationships.” The study consistently found that the quality and quantity of relationships, whether with caregivers, life partners or friends, is at least as strongly associated with health and longevity as well-known risk factors such as high cholesterol, smoking or obesity.

This finding squares with other evidence that loneliness and social isolation kill, that social support cures, and that a tight network of interpersonal connections is both buffer and blanket. Although our societies prize personal achievement, our technologies draw us away from in-person engagement and our lives become cluttered with busyness that takes priority over our social connections (“life is always at risk of slipping by unnoticed”), those connections remain paramount.

People tend to underestimate the benefits of linking up with others, over-value self-sufficiency and misallocate their time to asocial activities at the expense of interaction with loved ones. The happiest and most vital Harvard Study octogenarians have managed to avoid these traps.

Waldinger and Schulz examine the centrality of relationships from several standpoints. They discuss the developmental priorities of different life stages, the challenges and opportunities of intimate, family and work relationships, the special importance of friendships, and the ways of coping with stress that strengthen or weaken these relationships.

Given that the gradual withering away of friendships is a bleak and consequential reality for many people, especially men, avoiding interpersonal challenges or the effort of tending to them is a major risk. The Good Life argues for the importance of “social fitness” as an under-recognised source of good health that must be monitored, worked on and taught in schools.

The take-home message that social connection is the key to health and happiness is now almost common sense. But it was not always so. In the mid twentieth century, when the first wave of the Harvard Study began, the dominant view within the behavioural sciences was solidly individualist. Psychoanalysis, at the zenith of its influence in psychiatry, emphasised conflicts within the person as the source of human misery. Adult relationships were seen more as shadowy re-enactments of childhood dramas than as sources of health and strength. Even the psychosocial turn in psychoanalysis, led by Erik Erikson, saw the main developmental tasks of mid and late adulthood as fundamentally inward: finding a sense of personal contribution and integrity.

The leading psychologist of morality of the time, Harvard’s Lawrence Kohlberg, defined the highest level of moral reasoning as moving beyond social conventions and the social contract to a principled personal ethos. Influential humanistic ideas about motivation, such as Abraham Maslow’s famous hierarchy, placed the realisation of the unique self above social needs for esteem and love. Considering this intellectual matrix, the Harvard Study’s conclusions about the value of attachment, belonging and intimacy were not preordained, and they helped to shift the study of adult development and health in a relational direction.

Readers of The Good Life who are looking for a work of science communication will be disappointed. The authors provide few detailed reports of research findings and very few numbers. Although the book sits on a vast body of empirical results, Waldinger and Schulz rely much more on extended case studies of a few selected Harvard Study participants. Their professional identities as psychotherapists and, in Waldinger’s case, as a Zen priest, prevail over their identities as researchers.

As self-help books must, this one contains exercises and worksheets for those who wish to carry out their own relationship audit. But it is the life narratives that do the persuasive work by illustrating the uplifting message that relationships matter, that they can be cultivated and that it’s never too late to change them.

Bookish people and those who read quality online magazines often disdain works of popular psychology and self-help. The advice seems simplistic, the science flimsy and over-hyped, the tone annoyingly upbeat. We can understand and fix our unique and complex selves without that kind of asinine assistance. But there is little reason to think that sceptics have their relational house in order more than anyone else. The Good Life offers a useful guide to resisting the pull of self-reliance, personal striving and materialism, and instead investing our time and attention in other people. •

The Good Life and How to Live It: Lessons from the World’s Longest Study on Happiness
By Robert Waldinger and Marc Schulz | Penguin | $35 | 352 pages

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When Anthony Albanese promised to create an Australian Centre for Disease Control back in October 2020, partly inspired by the CDC, he was responding to Australia’s underpreparedness in the face of the Covid-19 pandemic. But Labor’s proposal reflects a much longer debate: since as far back as 1987 Australian public health experts have been calling for a dedicated body to advise government not just about threats from infectious diseases but also about preventive health measures.

Labor’s 2020 pledge focused on improving Australia’s response to future pandemics (and, indeed, better managing Covid’s ongoing effects). Its announcement highlighted the need for improved disease surveillance, better management of the National Medical Stockpile, regular preparedness drills, and close cooperation with state and territory governments and with other countries.

The ACDC is expected to take a key role in preventing, monitoring and managing infectious diseases, including unexpected contagions generated by climate change and resumed international travel. But every bit as vital will be its efforts to prevent the chronic diseases caused by lifestyle and environmental contaminants. Treasurer Jim Chalmers’s first budget provided $3.2 million in 2022–23 for design and consultations for this new agency.

In a discussion paper released last month, health minister Mark Butler says the ACDC will take “an ‘all-hazards’ approach to strengthening Australia’s ability to respond to a range of public health threats — both natural and those created by humankind.” Given the range of complex capabilities the ACDC could be expected to meet, it seems likely to be established in several phases.

As Butler envisages it, the first phase would include rebuilding the National Medical Stockpile, undertaking communicable disease surveillance, prevention and response, and ensuring greater data-sharing and data linkage. Other more controversial or more difficult elements will be incorporated in later years.

Butler and the Department of Health and Ageing are being inundated with advice and instructions. Writing for Croakey Health Media, public health specialist Terry Slevin outlined twenty-eight questions he believes the government’s discussion paper raises that must be addressed. VicHealth chief executive Sandro Demaio has listed six principles an ACDC must follow in order to be successful.

Two imperatives in particular are clear already from submissions and consultations. The ACDC shouldn’t duplicate existing functions but instead play a coordinating role. It must be given the necessary resources, key among them being an expert workforce and sustained, long-term funding.

While the public health sector is pushing for quick action and certainty, careful planning is critical and a staged rollout will help ensure there are no gaps and oversights. A commitment to boost the public health workforce and ensure a steady supply of needed expertise will be essential. The Public Health Association of Australia has called for a standardised national public health training program for all jurisdictions and for a more effective workforce distributed more equitably.

Australia has a reliable set of health statistics collected by a variety of government agencies, but it does a poor job of using this data for policy development and evaluation. Links between different datasets are limited, and little effort has been made to understand health disparities and inequalities. In many cases — as the most recent Closing the Gap report highlights — essential data for assessing health and social interventions is simply not available. The ACDC will need to tackle these gaps.

The general assumption is that the ACDC will also have health promotion and prevention responsibilities, although their scope is yet to be determined. The potential gains are enormous: chronic disease could be reduced by two-thirds by targeting lifestyle‐related risk factors, including tobacco use, obesity, alcohol misuse, physical inactivity and high blood pressure. Yet Australia lacks “a sustained, comprehensive and strategic approach to prevention, together with adequate funding, coordination and monitoring.”

Australia’s erratic “roller coaster” of preventive health efforts has been driven largely by ideology. Tony Abbott’s government, for example, abolished the Australian National Preventive Health Agency and ceased the National Partnership Agreement on Preventive Health in the 2014–15 federal budget.

But the Morrison government launched a National Preventive Health Strategy 2021–2030 in December last year and provided $30.1 million for its implementation. That strategy could very effectively be incorporated into the mandate of the ACDC. The newly established National Health Sustainability and Climate Unit might also sit well within the agency.

The ACDC’s effectiveness will depend heavily on its ability to communicate advice to political and policy decision-makers and guidance to the community. The pandemic has highlighted how trust, respect and appropriate targeting are essential for successful public health communication — and how this is rarely successfully contracted out to external consultancies.

All these issues are covered, at least to some extent, in the discussion paper’s seven design principles. But many stakeholders will need to be involved in the discussions and negotiations ahead. Key among them are the states, the territories and other federal agencies that may be reluctant to cede aspects of their current responsibilities.

These potential problems highlight the fact that this crucial new agency is being developed against the background of complex, under-resourced public health systems, state and federal, alongside a multiplicity of committees and advisory groups. The pandemic has also highlighted how, at times of national crisis, political decision-makers override expert advice and bodies designed to facilitate cooperation.

The ACDC will need the power to collect consistent national data (by contrast with how the states and territories all collected Covid-19 data differently) and to act when required (and perhaps even overrule local and state government decisions). It will also — drawing on the lessons of its American counterpart — need to be independent of both the federal health department and political interference.

The government would do well to make every effort to bulletproof this new agency against potential political attacks and efforts to claw back allocated funding. One way to safeguard the agency’s financial future would be to establish a “future fund” to ensure funding and remove funding decisions from the short-term political vagaries of the federal budget process.

The Medical Research Future Fund, established in the 2014–15 budget with funds taken from the health and Indigenous affairs budgets (including the National Preventive Health Agency and the National Partnership Agreement on Preventive Health) now has some $2 billion more in funds than the $20 billion goal: using some of these funds for an ACDC would be entirely appropriate.

The fact that Australia is the only country in the OECD without a Centre for Disease Control or equivalent should be turned to our advantage by assessing the best features of international exemplars. The discussion paper examines six — in Canada, Europe, France, Switzerland, Britain and the United States — and provides more detailed case studies for Canada and the United States. Canada is presumably singled out because, with both provincial and federal governments, it most closely resembles Australia.

An ACDC won’t solve all of Australia’s public health problems, and it would be a serious mistake to focus on the delivery of a new agency at the expense of other aspects of the public health systems. But it can play an important role in coordinating and reorienting Australia’s healthcare system. Whether all the stakeholders can be brought into agreement will ultimately depend on the leadership of health minister Butler and the investment foresight of treasurer Jim Chalmers. •

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It was a success according to its intentions. But that won’t take us very far. Its directors managed to evade almost completely an issue that is crucial to how Australia is to tackle the many, deep social problems spelt out by speakers on the floor of the Great Hall of Parliament House. I’ll come to that shortly.

The summit was intended to show Australians that our political climate has changed with the new government — and it did. The participants, speakers and moderators were mostly female. There was an abundant sprinkling of young faces, of non-white faces, of foreign accents. It looked and sounded like Australia.

The vibe was overwhelmingly positive. Political differences were set aside (except by the absent Peter Dutton). Everyone was given a chance to speak at some point, and most were worth listening to. Their contributions were mainly constructive.

The PM was his avuncular self, the friendly, trustworthy Uncle Albo, heir to the good Labor leaders of long ago. He urged the summit: “We have not gathered here to dig deeper trenches on the same old battlefield… Australians have conflict fatigue. They want politics to operate differently.” The contrast between his positivity and Dutton’s sniping showed why Australians, according to Newspoll, prefer him by a 61–22 margin.

This summit was a stage production. The cast spoke when they were meant to, and not otherwise. I didn’t see any debate on day one, though ANU vice-chancellor Brian Schmidt started some when he took the chair on day two. Mostly, if anyone wanted to disagree with what was being said, tough luck: they had no opportunity to do so. The “consensus” Anthony Albanese praised was more staged than real.

The summit was intended to produce a set of policy outcomes — and in a sense, it did. Soon after it ended, the government published a fourteen-page document listing what Treasurer Jim Chalmers described as thirty-six “concrete steps [it] intends to take… as an outcome of this… summit” plus a similar number of priorities for future discussion. Everyone got something to take back to their constituencies.

Seeing the speed with which the document appeared at the end of the summit, a cynic might wonder if, rather than responding to what it heard on the floor, the government took these decisions well before the summit, but held back the announcements to make it look like they came from the floor.

The summit was intended to highlight the importance — economic, social and political — of getting more women into work, into decision-making and into higher-level roles in the economy. And it did. Its three main policy themes were: how to fix the skills shortages in Australia’s workforce; how to change wage-fixing rules so that workers get a bigger share of the cake; and how to lift participation in the workforce. In the presentations, women’s work was central to all three.

Grattan Institute chief executive Danielle Wood sounded the bell in her opening keynote speech. Australia has one of the most gender-segregated workforces in the OECD, she noted, and market realities are now in sync with fairness in dictating that we tackle the underpayment of female-dominated caring occupations.

She cited an example: childcare workers are paid as little as $22 an hour, less than they could earn washing dishes at McDonald’s. No wonder we are perpetually short of them. Every year, Australia needs more than 33,000 more aged care workers, but they are grossly underpaid and overworked, so a huge turnover means a constant search for workers.

We can’t put off this issue anymore, and Labor’s leaders clearly recognise that. Treasury’s paper for the summit estimated that a quarter of Australia’s gender pay gap comes from low pay in the female-dominated caring and education professions. The Fair Work Commission is now hearing a case in which unions are seeking a 25 per cent pay rise for aged care workers. The government has promised to pick up the tab. That is where the action is.

But the obvious stage management of the summit should not obscure its genuine achievement. For two days, leaders of business, unions, community groups and federal, state and territory governments focused on contributing their knowledge, identifying the problems, finding common ground and scoping out solutions. They didn’t solve Australia’s problems, but they made progress on some fronts, and established good working relationships for future dialogue.

Yet the progress they made was marginal to the key issues facing Australia. Getting consensus meant the organisers could not allow the conference to tackle issues where consensus was impossible. Danielle Wood and fellow economist Ross Garnaut, the dinner speaker, certainly touched on some of them, but they were not targeted in any session.

One of them is crucial to almost every issue the summit addressed. It is tax.

The federal government is running deficits of $75 billion or more a year. While claimants were putting urgent cases to the summit for more spending in this area and that, Labor still insists on delivering an already-legislated tax cut, mainly for the rich, that will reduce tax revenues by 3 to 4 per cent. Where is it going to find the money to solve the problems the summit presented to it?

Garnaut pointed to the elephant in the room. “We have to stop kidding ourselves about the budget,” he said. “We have large deficits when our high terms of trade should be driving surpluses. Interest rates are rising on the eye-watering Commonwealth debt.

“We talk about the most difficult geo-strategic environment since the 1940s requiring much higher defence expenditure, but not about higher taxes to pay for it. We say we are underproviding for care and underpaying nurses, and underproviding for education and failing to adequately reward our teachers…

“[Yet] in the face of these immense budget challenges, total federal and state taxation revenue as a share of GDP is 5.7 percentage points lower than the developed country average.”

To put it another way, our governments every year raise roughly $120 billion less than they would if our tax rates were at the Western average. With that money, we could tackle every issue raised at the summit. The government, if it chose, could finance 25 per cent pay rises for aged care and childcare workers, raise the dole to $70 a day, restore the funding the Liberals took from universities, invest in research and new technology, pay the states 50 per cent of hospital costs, give state schools their fair share of funding, etc., etc. — and close the deficit.

There are many good ways to raise revenue. Australia has an abundance of tax loopholes allowing companies and individuals to avoid tax: negative gearing is a classic example, but as the International Monetary Fund once suggested, Australia could apply the same principle to business, and stop firms deducting interest bills from their tax.

In the June quarter, the Australian Bureau of Statistics tells us, the total wage bill for Australia’s millions of corporate employees was $164 billion, while its mining companies made a gross operating profit of $81 billion. In just three months! If any country ever had cause to levy a tax on super profits it is Australia, now. Jim Chalmers needs to make this a centrepiece of his October budget.

But no one in the sessions I heard mentioned tax in their speeches. Like all those who argue for more spending on worthy causes, they urged more spending without a word on how the government should find the money to pay for it. Tax is the issue we don’t talk about. The summit would have had more cutting edge if some delegates had dared do so.

There’s been little argument over the summit “outcomes” because they are mostly agreements on principles, aspirations, processes or short-term supports to be applied while longer-term outcomes are negotiated.

They are modest: first steps, not solutions. Maybe they needed to be to get tripartite agreement between government, business and unions. And having tripartite agreement on sensible first steps in the right direction gives the government more freedom to plan bolder steps to solve the problems.

One of the summit’s big moves to tackle the skills shortage, for example, was to increase the permanent migration target for 2022–23 from 160,000 a year to 195,000. Almost all that increase will comprise skilled workers and their families, mostly sponsored by state governments (who are primarily chasing health workers) and employers in the regions.

No one objected to that. Nor should they, because if the target follows current patterns, it will make little difference. In recent years, two-thirds of permanent residence places were awarded to migrants already in Australia, working or studying on temporary visas.

And while the government would like to bring in new migrants to help reduce our skills shortage, particularly in hospitals and aged care, it has an even more urgent priority: tackling the scandalous backlog of unprocessed visa applications piled up by the Department of Home Affairs under the Morrison government.

Immigration minister Andrew Giles told the summit Labor inherited a backlog from the Coalition of almost a million unprocessed visa applications. It was an unbelievable number, including applications from all types of people: separated partners, skilled workers, overseas students, business. Brian Schmidt recalled the department taking twenty-one months to process the ANU’s applications to bring in some Indian academics — for three-year appointments.

Giles said the government has now swung an extra 180 staff onto clearing the visa backlog, and has so far reduced it by 100,000. One of the thirty-six “outcomes” was that it will now spend an extra $36 million to lift visa staff by 500 people for the rest of this financial year.

But the waiting list includes a staggering 330,000 people who are already in Australia on bridging visas until their applications are processed. It’s fair to assume that many, maybe most, of them are applying for permanent visas. Given the scale of this backlog, an increase of only 35,000 in the migration target seems extraordinarily timid. Labor will have to revisit that, and soon.

The big “outcome” for the young unemployed and school leavers was the agreement by the prime minister and premiers to pump $1 billion into TAFE in 2023 to provide 180,000 extra fee-free places while they negotiate a longer-term agreement to reform the sector. Again, you applaud the direction — and in this case, the boldness and the federal–state cooperation — but it’s only a short-term solution.

Another “outcome” was Albanese’s announcement that, as an inducement for older workers to keep working, or retirees to return to work, pensioners will be allowed to earn an extra $4000 — just for this financial year — without losing any of their pension.

Good, but I think the PM is safe from being knocked down by a stampede. For a few months, it might induce some pensioners to put in a few hours a week at some nearby workplace. But why make it so small? Why end it on 30 June? It’s almost as if it was designed to avoid having any substantial impact. It’s tokenism, when big gains are possible from a comprehensive policy to extend working lives for those who want to keep going.

Chalmers and finance minister Katy Gallagher routinely fob off questions about spending proposals such as raising the Jobseeker allowance by declaring sympathetically, “There are lots of good ideas out there, and I wish we could fund them all. But we have inherited a trillion dollars of Liberal debt…”

Someone must call that out. First, Table 9.2 of the 2022–23 budget papers implies that Labor inherited $979 billion of gross debt from the Liberals — but $303 billion of that was inherited in 2013 by the Liberals from Labor (who in turn inherited $64 billion in 2007 from the Liberals, and so on). It’s Liberal and Labor debt. It’s Australia’s debt.

Second, gross debt looks at just one side of the balance sheet — which is why we focus on net debt. Table 9.2 estimates Labor inherited $631.5 billion of net debt from the Liberals, who in turn inherited $161.6 billion of net debt from Labor back in 2013. It’s a cheap, false political point.

But on the first part of its routine line, Labor is right: there are a lot of good ideas out there, and the government can’t fund them all. Its job is to sift through them and set the priorities. And if it picks a bad priority, such as backing the Liberals’ stage three tax cuts, it sticks out like a sore thumb.

These cuts were Morrison at his worst. They do not take effect until mid 2024, yet became law in 2019 — with Labor’s support, because it was frightened of being depicted as a high-tax party. This is the legislation that will give tax cuts of almost $175 a week to someone earning $200,000 a year, and $2 a week to someone earning $50,000.

The Parliamentary Budget Office estimates the cuts will deprive the government of $243.5 billion of revenue — 3 to 4 per cent of budget revenue — over their first nine years alone. The PBO says 78 per cent of that will go to the richest 20 per cent of households: by definition, those who need it least. And that, at a time when the budget is perpetually in deficit, and the government assailed on all fronts for spending too little.

The summit’s speeches ranged far and wide. Many speakers gave interesting accounts of what they were doing, or their experiences dealing with the systems now in place. Highlights are on YouTube, and the entire summit can be seen on Parliament’s video stream.

Transcripts regrettably are not available, except on ministerial websites and those of some speakers. I recommend Danielle Wood’s challenging and probing overview of Australia’s economic potential, which castigated business leaders for their risk-averse “economic funk,” and called for Australia to adopt “full employment as our lodestar” and remember that, if we want to raise living standards, in the long run, “productivity is almost everything.”

Peter Davidson, principal advisor to the Australian Council of Social Service, also made a lot of challenging points in urging Labor to reform the employment services system. “The system [has] not been working for a long time,” he said. “Jobactive was more of an unemployment payment compliance system than an employment service. It sent people out into the labour market and when they didn’t find jobs, told them to search harder. People were literally told: ‘It’s not our role to find you a job.’”

Ross Garnaut’s dinner speech recounted the reasons for Australia’s success in the postwar era, and the challenges reformers faced then — and in the Hawke-Keating era — and now. “I grew up in a Menzies world of full employment,” he recalled. “Workers could leave jobs that didn’t suit them and quickly find others. Employers put large amounts of effort into training and retaining workers. Labour income was secure and could support a loan to buy a house. Steadily rising real wages encouraged economisation on labour, which lifted productivity.”

In the postwar era, and in the 1980s, Garnaut said, “success was based on using economic analysis and information to develop policies in the public interest; on seeing equitable distribution of the benefits of growth as a central objective; and on sharing knowledge through the community about economic policy choices. This built support for policies that challenged old prejudices and vested interests.

“Personal and corporate taxation rates were much higher than before the war. Full employment and a wider social safety net supported structural change and much larger and more diverse immigration… Menzies’s political success was built on full employment — helped by Menzies insulating policy from the influence of political donations to an extent that is shocking today.”

Garnaut ended by exhorting Albanese and Chalmers to follow the path of Hawke and Keating, strong politicians who took big risks to bring in reforms when they were clearly needed. “We have to raise much more revenue while increasing labour force participation and investment,” he said, urging two radical reforms he advocated last year in his book Reset: a guaranteed income scheme, and a shift to cash flow taxation of business.

But Albo is not Hawke and Chalmers is not Keating. Like the business leaders who have dragged down Australia’s business investment to the lowest share of GDP ever recorded, they are risk-averse. Their priority is to retain power, and they see the way to do that is by giving people what they want, not trying to persuade them that tackling tough reforms is in the national interest.

It is possible, though, even likely, that they will end up having no choice. The crisis in aged care, in hospitals, in GP practices, in childcare and in teaching will force an end to governments’ model of saving money by underpaying those who work for you (or whose wages you pay indirectly). Australia’s system of doing government on the cheap has been tried, and failed. We are going to have to learn from how the rest of the West does it, and that means raising taxes.

Many have noted that the Hawke government, like this one, began its term by staging an economic summit, which brought business and union leaders to Old Parliament House with the similar aim of “bringing Australia together” to tackle its economic problems. But we should also recall that its follow-up two years later was to invite a similar cast for a tax summit.

That is what Albanese and his team should start planning for. We cannot solve our problems without an honest national dialogue on the need for higher taxes, and where we should be looking for increased revenue. It could be combined with the announcement of a super profits tax on mining companies and the big banks. Reform needs to start now. •

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Five years on, it’s officially a problem. At a business dinner in July, a manager and client of the ecommerce giant Alibaba pushed a female employee to get drunk and then sexually harassed and raped her. The distressed young woman reported the incident to her superiors and Alibaba’s human resources division. When they took no action, she posted an eleven-page account on the company’s intranet.

Word got out and Chinese social media blew up. The hashtag “firmly refuse vile business drinking culture” attracted 220 million views and tens of thousands of comments. Alibaba CEO Daniel Zhang went public to condemn the “ugly culture of forced drinking” and fired the alleged rapist. Two other managers who had failed to act on the woman’s complaint resigned. Even the Communist Party’s powerful anti-corruption body, the Central Commission for Discipline Inspection weighed in, condemning the culture of compulsory drinking at business and other dinners as “odious.”

Out came other shocking stories of sexual assault and more. There was the boss who slapped a new employee for not returning a toast by a higher-up, and the professor who forced a postgrad student to drink so much he passed out — and then refused to teach him because he wasn’t a good enough drinker. Criticisms of the contemporary drinking culture — endless forced toasts, typically with strong spirits called baijiu, and a bullying power dynamic — had been growing for years. In 2021, they reached critical mass.

Some commentators have pushed back. Drinking, they claim, is part of traditional Chinese culture. The ancient Book of Odes, compiled almost three millennia ago, contains at least twenty references to alcohol. Wine played a role in formal rites and rituals. One of the most famous works of calligraphy, “Preface to the Orchid Pavilion Poems,” celebrates an afternoon playing a game involving drinking and poetry.

One of the pithiest and most-quoted tributes to drink came from the brush of Cao Cao (155–220), a military man and a poet. Part of a longer poem, it honours the semi-mythical inventor of fermented drink, Du Kang: “How to dispel one’s sorrows? Only Du Kang.”

Li Bai (701–762), considered one of China’s two greatest poets, was a renowned inebriate. Among his many tributes to the joys of intoxication, he penned the following lines, which may well resonate with the generation of young burnt-out workers who talk longingly of “lying flat” (dropping out and doing nothing), here translated by Amy Lowell and Florence Ayscough: “Why should one spend one’s life in toil?/Thinking this, I have been drunk all day./I fell down and lay prone by the pillars in front of the house.”

Yet the drinking culture of old was not quite what it seems. For one thing, when Li Bai, in another poem, hails “a cup, a cup, and yet another cup,” he is talking about a very small cup, filled with wine fermented from fruit such as grapes, or grains such as rice or sorghum, with an alcoholic content well under 20 per cent.

Distilled spirits, baijiu, only came to be produced in significant quantities sometime in the Ming dynasty (1368–1644). Up to 70 per cent pure alcohol, baijiu was cheap and potent, predominantly a drink of the poor. It did not appear at the banquets of the rich or powerful, nor did it fill the poets’ tiny cups.

Everything changed in 1935, when an army marched with sore feet into a small village in southwestern Guizhou province. The Communists’ Red Army was in the middle of the legendary Long March, a tortuous, two-year, 9000-kilometre retreat, during which it fought off bandits, warlords and attacks by government troops while traversing some of China’s most rugged terrain, from malarial swamps to snowy mountains.

In the Guizhou town of Zunyi, the Communists made Mao Zedong their leader. In the village of Maotai, they made the fierce local baijiu their drink. It didn’t just numb pain and stave off cold. It could sterilise wounds as well, and, as Red Army generals discovered to their delight, it was perfect for soaking their blistered, aching feet.

After the Communists took power in 1949, the state nationalised and combined the handful of baijiu distilleries in Maotai, and named the product after the village (spelling it Moutai in English). In 1951, premier Zhou Enlai created a standard for state banquets. The food would be of the refined and not-too-spicy southeastern Huaiyang cuisine. The drink would be the fiery Moutai. The proletarian sauce that had played such a welcome role in one of the party’s foundational legends became the national drink of the People’s Republic of China.

Baijiu manufacture boomed. In 1949, China produced 108,000 tonnes of baijiu; by 1975, annual production had reached more than 1.7 million. The Soviet Union, where no deals were done without lashings of vodka, also contributed to the reshaping of China’s drinking culture, especially among officials. Online commentators looking for the source of China’s toxic drinking culture point the finger at one man in particular: Dmitry Ustinov, the Soviet central committee member responsible for the Soviet Union’s military-industrial complex from 1965 to 1976 and defence minister from 1976 to 1984.

Some of Ustinov’s Soviet colleagues claimed he put an end to messy drinking culture within the Soviet defence establishment. By contrast, Chinese accounts, which credit Ustinov with an almost inhuman ability to hold his liquor, relate how he notoriously insisted that negotiations, over arms deals for example, begin with marathon bouts of drinking. He would get his guests so thoroughly pixelated that they would sign off on deals they’d wholly regret in the morning. In one infamous example, when India was trying to talk down the price of Soviet arms, six Indian negotiators ended up in hospital with alcohol poisoning; the ones who remained upright blearily agreed to double the original price.

In the early 1990s, in a case of what you might call “reverse Ustinov,” the Chinese historian of Sino-Soviet relations and the cold war, Shen Zhihua, fed up with the obstructively slow pace of Russian archivists, plied them with baijiu. The files fell open.

It was in the 1990s that the Chinese Communist Party expanded its economic reforms and businesses boomed. Entrepreneurs readily adopted official, Sovietised banquet culture, with its baked-in hierarchies and negotiations over endless toasts of baijiu. To refuse a drink was to cause one’s superior or host to lose face, or so they said. And a sip wouldn’t do — the expression ganbei was a command to drain the glass in one go. A straight line led from here to the scandal at Alibaba.

Forcing people to drink as a sign of subservience was not unknown in ancient times. Cao Cao is said to have laid on a banquet for a general who surrendered to him at which he toasted each guest in turn, a strongman with an axe by his side. Refusal was not an option.

These days, China leads the world in total alcohol consumption. The legal drinking age is eighteen, although enforcement is, to say the least, patchy. But China’s younger generation, and especially those among its better-educated, well-travelled middle class, are increasingly rebelling against “bottoms up” culture. A recent survey revealed that people under forty tend to consider baijiu both bad-tasting and old-fashioned; many prefer beer and wine and even low-alcohol drinks, and bars over banquets.

In another online survey, 84 per cent of the almost 700,000 respondents expressed “extreme disgust and zero tolerance” for coercive drinking at business and other banquets. Baijiu production peaked in 2016 at 13.6 million tonnes; by 2020 it dropped to less than 7.5 million.

At one point in my misspent youth, as a young magazine reporter attending a banquet with officials from the All-China Journalists Association in Beijing, I acceded to a drinking contest. Twenty glasses of Moutai later, I declared victory. The following morning, I woke up with drums in my head, the imprint of a toilet seat on my cheek, and colour literally drained from my vision for several terrifying, sepia-tinted hours. An end to coercive and competitive drinking? I say cheers to that. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

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The most glaring example is the lack of systematic action on climate change. Australia drags the chain on emissions reduction and continues to punt on energy-intensive exports with a dwindling customer base. A price on carbon wouldn’t have solved all our climate challenges, but it would have left us better placed than we are now.

The failure to rein in house prices is another case in point. The tax system has helped turn housing into a speculative asset, pushing funds into property rather than productive sectors of the economy, driving household debt to spectacular levels, and ramping up inequality. Again, reforming the tax treatment of residential property would hardly solve all our housing woes, but it would ameliorate some of the real estate boom’s worst effects.

In a new essay in Monash University Publishing’s “In the National Interest” series, Wayne Errington and Peter van Onselen argue that carbon pricing and property tax reform have become “pariah policies.” Despite evidence that they would have a net positive impact on Australian society, these measures have become untouchable. Events bolster their case: as we gear up for a federal election, Labor has walked away from its modest reforms to negative gearing and capital gains, and the phrases “carbon price” and “emissions trading” are banned from its political lexicon.

But, Errington and van Onselen argue, weak opposition means poor government: “The progressive side of the two-party divide is too inept to apply pressure to the conservative side, meaning conservatives stay in government without lifting their game.”

The title of their short book is Who Dares Loses. If this bleak declaration is true, then ambitious policy proposals are a recipe for electoral defeat, which appears to be the conclusion Labor has drawn from its loss in 2019. The flip side is that winners aren’t reformers. Having achieved office, governments avoid risking political capital to change society for the better.

Errington and van Onselen set out to “selectively challenge the conventional wisdom” by arguing the case for several “pariah policies,” including a universal basic income, the reintroduction of estate duties, a tax on the family home, a price on carbon, a levy on sugar, and the commercialisation of the ABC. Some of their arguments are convincing, others less so.

The case for a levy on sugar is strong. It would induce manufacturers to produce healthier food and encourage consumers to eat it, reducing the burden of diseases like diabetes and raising extra health dollars to boot. The idea that education campaigns and better labelling can drive this much-needed behavioural change was debunked long ago.

By contrast, the case for putting ads on the ABC is thin. Bizarrely, the authors propose this as a way of countering the decline of quality journalism in Australia. Their argument runs as follows: having lost valuable revenue streams like classified ads, commercial media have cut their newsrooms to the bone; as a result, subsidies for investigative reporting and quality debate must now “reach beyond the current public broadcasters.” So far so good — the case for funding more public interest journalism is strong. But their conclusion — that the ABC, like SBS, “will have to generate more of its own revenue” — is a non sequitur.

Are budget constraints so great that we can only increase funding in one area by reducing it in another? Believing that would be inconsistent with Errington and van Onselen’s support for a universal basic income, at an estimated $125 billion annual cost they claim “isn’t quite as eye-watering” as it may have seemed before JobKeeper.

In order to get more of the public interest journalism and investigative reporting that the ABC still does well, they want to make the ABC more like the commercial media. With the ABC competing for ads, they say, the other networks “would have a market incentive to lift their standard of news coverage, in a bid to steal ABC viewers and their lucrative advertisers.”

The reverse scenario is far more likely — the ABC would move downmarket as it sought to peel advertising dollars away from its (more) commercial rivals. And if it succeeded, the government would quickly cut public funding accordingly.

The “pariah policies” in Who Dares Loses overlap significantly with the reforms identified by the former chief executive of Grattan Institute, John Daley, in his recent report, Gridlock. Daley identifies carbon pricing, the tax treatment of housing, and sugar taxes as areas where government action has stalled. (He doesn’t mention commercialising the ABC.) Other initiatives consigned to the too-hard basket include congestion charging on roads, raising the pension age, introducing an effective mining resource rent tax, broadening (or increasing) the GST and lifting unemployment benefits.

Gridlock sets out to answer three questions. To the first — are twenty-first-century governments more reform-averse than their predecessors? — Daley’s answer is an emphatic yes. The 1980s and 1990s under Bob Hawke, Paul Keating and, initially at least, John Howard were “golden years” for reform. We might argue about the relative merits of measures like floating the dollar, cutting tariffs, deregulating the banks, introducing compulsory superannuation, imposing the GST, and privatising Telstra, Qantas and the Commonwealth Bank, but it is hard to dispute Daley’s contention that recent governments have been far less ambitious.

Daley’s second, more difficult, question is why are contemporary governments so timid? He identifies three obstacles that seem to be stopping governments from tackling major reforms: the lack of popular support for particular changes; the power of the “shibboleths” that mark out loyalties within parties or factions; and the opposition of powerful interest groups. The size of the required budget investment can also be a barrier, but Daley dismisses as relatively insignificant two of the most oft-cited roadblocks — the Senate and the messy division of responsibilities between the Canberra and the states.

But these obstacles aren’t new. The GST was deeply unpopular, but Howard risked electoral defeat to go ahead anyway. Privatising the Commonwealth Bank contradicted Labor shibboleths, but Hawke and Keating pressed on regardless. Vested interests vigorously opposed native title legislation, but it was still steered through parliament.

What’s different today? The glib response is that we’ve stopped electing politicians willing to push through obstacles in the belief that the change is worth the fight. As we contemplate an unedifying electoral contest between “ScoMo” and “Albo,” it’s easy to believe that current leaders don’t measure up to leaders past. That might be an emotionally satisfying answer, but it leaves us hoping forlornly that someone better will eventually turn up.

Deeper answers lie in structural economic and social changes. The echo chamber of social media has driven polarisation and division. The twenty-four-hour news cycle and the professionalisation of politics mean policies are more likely to be shaped by polling and focus groups than by evidence. The shifting and shrinking bases of the major political parties have reinforced polarisation.

Meanwhile, the hollowing out of the public service, the rising power of political staffers and the outsourcing of advice to corporate consultancies have weakened governments’ capacity to generate and implement good ideas. And the “revolving door” that turns a ministerial adviser into a “government relations” professional has picked up pace, as has the “golden escalator” from ministerial portfolio to corporate board or strategic advisory role.

Daley’s third question is obvious: what is to be done? If we want more ambitious, reform-minded leaders, we need to change the system that supports the current epidemic of policy timidity. “Institutional changes to ministerial adviser roles, to processes for appointing and dismissing senior public servants, to ministerial influence over government contracts and grants, and to controls over political donations, campaign finance, lobbying, and post-politics careers would all help to break the gridlock in policy reform,” he writes.

Errington and van Onselen recommend similar changes, and throw in a shift to proportional representation. If New Zealand can change its electoral system, why can’t we? The catch, as always, is that the people we need to fix these problems are a big part of the problem. As Daley says, the institutional changes he proposes “are themselves an example of blocked policy reform.” If our political caste can’t manage to abolish franking credits, let alone create a federal corruption commission, then the chances of substantial systemic reform appear slim.

Daley puts his hope in more independent MPs getting elected to parliament and using the balance of power to force systemic change. It’s hardly a quick fix, but it chimes with the fact that the reform highlights of the past two decades — including the (shortlived) carbon pricing mechanism, the NDIS, the Gonski school funding scheme, and plain-paper cigarettes packaging — mostly came when Julia Gillard was leading a government reliant on crossbench MPs.

Daley’s conclusion suggests the answer lies in getting back to the basics of political organisation at the local level: engaging citizens, listening to their concerns, and involving them in developing campaigns and policies. This is the nuts-and-bolts work that helped the campaign for marriage equality succeed. It is the kind of community organising that elected independent Cathy McGowan in the formerly safe Liberal seat of Indi in 2013, and enabled Helen Haines to succeed her in 2019.

In other words, we need to build democracy from the bottom up, not suffer it from the top down. Electing more independents to parliament seems like a good place to start. •

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It begins with a paradox. As we learned at a subsequent presser, 70 per cent of cases are being transmitted among household members. So why focus on workplaces? We all understand that the virus travels through the networks established when people spend time together. When it gets into a household, Delta rapidly infects everyone living there, and often their extended family as well, generating a big spike in case numbers.

But we need to be asking how it reaches households in the first place.

When we describe workplaces as melting pots, we mean they are places where people who don’t otherwise know each other are mixing, creating links among household and family networks that wouldn’t otherwise exist. If we want to prevent the household clusters that generate big numbers, we need to eliminate these “bridging” cases.

Restrictions are not simply intended to ensure everyone stays at home so that nobody can possibly be infected. Their little-recognised goal is to reduce the mixing rate among people from different networks.

Not understanding this, we fear the wrong thing. The general public and the news media worry enormously about casual contact among people in public spaces. But as Victoria’s second wave demonstrates, when Covid-19 gets into workplaces, that’s when the trouble really begins. Introducing 9pm curfews, increasing police presence on street corners, and wearing masks at all times in public have zero effect on this crucial transmission mechanism.

Lockdown’s Achilles heel is it almost never extends to essential workers. Our click-and-collect orders aren’t going to pack themselves. We need workers to drive trucks and stack shelves with food, not to mention the toilet paper we run out of. Healthcare, aged care and disability services must continue. And all of this permits workplace transmission to continue even as restrictions get tighter and tighter.

It’s no accident that transmission is concentrated in the areas of Sydney with the highest proportion of precarious migrant workers. In communities like these, people need dense social networks offering practical, spiritual and cultural support to survive under pressure. This “network topology” facilitates transmission of contagious pathogens.

Informal aged care, for example, is extremely common in migrant communities. Gladys Berejiklian keeps talking about people in large families visiting other households, as if they’re getting together for long lunches. But what we’re talking about is family members taking turns to bring food and provide care to grandma. You can’t just stop doing that, no matter how steep the penalties become.

The other problem with network-driven outbreaks is that they are really hard to model. Estimating transmission rates depends on understanding the network landscape, and that’s exceptionally difficult to map in real time. You can’t do it using the abstract mathematical models that dominate our public debate.

At long last, we’re beginning to see discussion of these modelling shortfalls. Models that assume the population is a monolith ignore the heterogeneity of networks and groups, which can sustain ongoing transmission even when the population is under lockdown or 80 per cent vaccinated overall.

We need to lockdown smarter, not harder. This means a lockdown that responds to the network contours of the outbreak in front of us.

Outspoken public commentators have learned all the wrong lessons from Victoria’s second wave. Rather than copying interventions that apply to low-risk activities in public — curfews, limits on exercise, playground closures and mask-wearing in public — we should look at what Victoria did to limit workplace mixing.

Under the restricted activity directions enacted on 5 August last year, the Victorian government imposed extremely detailed limits on workplace occupancy. The meat industry was reduced to two-thirds of employees on-site, while construction was reduced to “pilot light” levels, at 25 per cent of normal workforce.

So far in New South Wales, the burden has been placed on the shoulders of workers in “LGAs of concern,” including a requirement to get swabbed every three days before leaving the local government area for work. But with Delta, a lot can happen in three days. To drive cases towards zero, strict limits must be applied to employers rather than employees.

And there’s the rub. The NSW premier must manage three factions in her cabinet. One favours a public health response to the crisis, following health advice from Chant. Another demands (with increasing success) a law-and-order response. And a third, in the ascendant, demands freedom for industry and the economy.

Backed by the PM, Berejiklian has adopted the line that we need to learn to live with the virus. As the state moves towards 80 per cent double-dose vaccination in the community, she says, what will matter is not the daily case rate but numbers of hospitalisations and deaths. This is primarily consistent with the demand for economic liberalisation.

A health equity perspective tells us that an 80 per cent average will conceal pockets of the community where vaccination rates are much lower. If New South Wales opens up at that point, this heterogeneity will sustain ongoing outbreaks. These will include breakthrough infections among the vaccinated, but will concentrate illness and death among precarious and vulnerable groups.

Rather than going harder and harder until the heat death of the universe, a smart lockdown would make greater use of soft skills. Instead of putting police and the military on the streets of LGAs with significant migrant populations from war-torn countries, it would further invest in building the capacity of affected communities to respond to the outbreak.

The same interpersonal networks that can transmit a pathogen or misinformation can be harnessed to pass on resources and skills for protecting yourself, your loved ones and your community from the crisis. As we have learned from the HIV/AIDS crisis, highly mobilised communities are more powerful in promoting health than any punitive response. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

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Twice this month, large numbers of people have gathered at demonstrations in French Polynesia’s capital Papeete. As they prepare for Macron’s arrival, church and community organisations have joined with the independence party Tāvini Huira’atira nō Te Ao Mäòhi to call for action on the health and environmental consequences of thirty years of atmospheric and underground testing at Moruroa and Fangataufa atolls. Under the banner “Mäòhi Lives Matter!” thousands of people have rallied seeking reparations for people affected by the radioactive fallout that spread across French Polynesia’s five archipelagos.

During a 2016 visit to Tahiti, Macron’s predecessor François Hollande pledged action — still incomplete — on nuclear clean-up and compensation. Now it’s Macron’s turn to make the same pilgrimage. More pledges are expected from the French president, but many locals fear he won’t be able to fulfil his commitments before the next presidential election in April 2022.

To frame the president’s three-day tour of the Marquesas Islands, the Tuamotu archipelago and Tahiti, the French government organised a roundtable on nuclear issues in Paris on 1–2 July. But the idea of discussing nuclear legacies in Paris rather than Papeete raised hackles among nuclear survivors.

The leaders of Moruroa e Tatou, an association uniting Mäòhi workers who staffed the nuclear test sites, announced they would boycott the meeting. They were joined by church leaders and Association 193, an organisation that aids nuclear survivors and educates a younger generation. Reverend François Pihaate, president of the Église Protestante Mäòhi — the largest religious denomination in French Polynesia — joined other Mäòhi leaders to dismiss pledges from François Hollande and Emmanuel Macron.

“It’s always the same song, it’s just the singer that changes,” says Pihaate. “The health and dignity of the Mäòhi people, scarred by these tests, is not negotiable at a roundtable.”

Opposition politicians Gaston Flosse and Oscar Manutahi Temaru — both former presidents of French Polynesia — condemned the roundtable as a stunt. Two of French Polynesia’s deputies in the French National Assembly also refused to attend: Moetai Brotherson of the opposition Tāvini Huira’atira party and Nicole Sanquer of the governing Tapura Huira’atira.

Announcing her boycott just days before the roundtable, Sanquer made clear her disagreement with the leader of her party, French Polynesian president Édouard Fritch. “The delegation organised by President Fritch to participate in this meeting is not representative of our country,” she said in a statement. “The community associations and political movements that have fought for several decades to obtain more truth on this question will not participate, for legitimate reasons that they have already indicated or simply because they haven’t even been invited. It is necessary to state that behind all the speeches and the posturing, little has really changed.”

Moetai Brotherson tells me he was initially undecided about attending. “On the one hand, I don’t usually support a policy of ‘the empty chair,’” he says. “I thought it might be important to be a direct witness of what was happening behind closed doors. But now I’ve seen what happened, I’m so glad I didn’t participate in this farce, with the total lack of respect to the Polynesian people and to the victims of the nuclear tests.”

Despite these criticisms, President Fritch and an eighteen-member delegation attended the roundtable. The Reko Tiko (“speaking the truth”) delegation joined a series of discussions chaired by French health minister Olivier Véran, overseas minister Sébastien Lecornu and Geneviève Darrieussecq, who goes by the impressive title of “Minister Delegate to the Minister of the Armed Forces, in charge of Memory and Veterans.”

The differing perspectives and priorities among participants quickly became clear. The French government may have a minister in charge of memory, but it wants to ignore the passions that still drive the survivors of thirty years of nuclear testing.

French officials briefed the media that the meeting would study the issues “without emotion,” in an “objective” manner. The overseas ministry pledged an open book, proposing “the objective of sharing information without taboos, both on the period of the tests and on the impacts of the bomb in French Polynesia, in a meeting held under the banner of transparency.” The health ministry wanted to develop an up-to-date body of knowledge “because there is a need to rely on scientific knowledge to objectify and reduce uncertainties and misunderstandings.”

While Darrieussecq acknowledged that “we must take responsibility for all the consequences, human, societal, health, environmental and economic,” she said there would be no apology from France. “We are not at all in the business of forgiveness. We are addressing national matters and the construction of our national defence. French Polynesia continues to be an essential link in our military forces today.”

On the sidelines of the meeting, Darrieussecq briefed Agence France-Presse that “there had been no lies by the State.” It is this claim that so annoys most French Polynesians — especially coming from a minister responsible for “memory.”

Even as a loyal supporter of the French Republic, president Édouard Fritch has acknowledged that many politicians lied about the hazards of the testing program. As he told the Assembly of French Polynesia in November 2018, “For thirty years we lied to the people that the tests were clean. We lied. I was part of this gang. Why did we lie when our own leader saw a bomb go off? When you see an atomic bomb go off, I think you realise that it can’t help but hurt. For thirty years we said the truth is ‘it was clean.’ This is the reason why I am investing myself enormously today in this affair, recognising I owe a lot to my people.”

Other Mäòhi recall the silencing of those who dared to challenge the nuclear build-up, including the unjust conviction and exile of Tahitian nationalist Pouvana’a a Oopa in the 1950s, and the 1985 sinking of the Rainbow Warrior in Auckland Harbour, an act of state terrorism that caused the death of Fernando Pereira. Today, in Aotearoa New Zealand and across the region, people have not forgotten: Auckland Museum has just launched an exhibition on “Remembering Moruroa.”

France’s claims of transparency are also belied by the ongoing debate about the declassification of archival documents from the nuclear testing era. For decades, many crucial documents — especially those detailing levels of radioactive contamination — have been inaccessible to independent researchers, medical experts and even the government of French Polynesia.

Darrieussecq pledged after the roundtable that a working group “including a Polynesian representative” would be established in Paris in September to look at how to open up the nuclear archives. “We have nothing to hide,” she added, “apart from information that could be used for weapons proliferation and which endangers the security of France and the world.”

For French Polynesian deputy Moetai Brotherson, this pledge is sleight of hand, given that a longstanding legal case to open up the national archives was already before France’s highest administrative court. “It has nothing to do with the roundtable,” says Brotherson. “This was already in the pipeline, pending at the Conseil d’État.”

At the same time as the roundtable, the Conseil d’État overturned provisions of 2011 legislation that had extended the classification of documents from twenty-five to fifty years, especially those related to national security. One objectionable provision of the law was that any document with a classified stamp had to be restamped “declassified” before it could be released, but that action could only be undertaken by the agency that classified the document in the first place. The fifty-year timeline was measured from the last, not the first, document contained in a file.

Many French historians and researchers remain sceptical that the army and defence ministry will open up their archives in a timely way to fill in the gaps in what’s known about the nuclear program. Will French bureaucrats be eager to reveal the sorry history of public disinformation issued by successive governments over many decades?

This debate over paperwork angers many former Moruroa workers, whose compensation claims are repeatedly rejected because they can’t provide documentary evidence of their work on the test sites. The classification of radiation dose levels makes it hard to prove a connection between their service on Moruroa and current cancers, leukaemia or other health effects.

Debate about the radioactive legacies of French nuclear testing exploded again last March, after the publication of Toxique, a book by investigative journalist Tomas Statius and Sébastien Philippe, a researcher at Princeton University’s Program on Science and Global Security. Statius and Philippe analyse more than 2000 documents from the French defence ministry, now made available on the Moruroa Files website. While much of the book draws on work by previous researchers, it re-evaluates the extent of the radioactive contamination between 1966 and 1974. It shows, for example, that the 17 July 1974 test codenamed Centaure spread fallout as far as Tahiti, exposing the 80,000 inhabitants of Papeete to hazardous levels of ionising radiation.

Toxique has caused a stir in France, although the authors were not invited to the recent roundtable to discuss their work. Many people in French Polynesia, however, have been documenting this reality for many years. Before his death in 2017, researcher Bruno Barrillot published a series of books detailing the exposure levels of workers at Moruroa and hazards to communities on neighbouring islands.

Barrillot also served as key technical adviser to a 2005 inquiry into nuclear testing conducted by the Assembly of French Polynesia. This parliamentary commission, chaired by Assembly member Unutea Hirshon, published two volumes of findings the following year that drew on the testimony of nuclear survivors as well as official archives. Hirshon says the inquiry was only possible after the local elections that brought independence leader Oscar Temaru to the presidency in 2004, an era known as the Taui (change).

“A few weeks after we won the elections, I was given the opportunity to preside over the special committee into the consequences of atmospheric nuclear testing,” she recalls. “Because this inquiry was within the parliament, it was very hard for the French or the local authorities to prevent us asking people to testify: whether they were involved at that time, or people from the weather bureau, scientists and specialists.”

The time was right for the inquiry, she adds, because people felt safe to testify. “Many were local people who knew a lot about the testing, but they had been scared. There was like a cloud: ‘You don’t talk!’ So it was during the Taui, this time of change, that we could show there had been impacts on the population and damage to the environment.”

Back in Paris, one of the few positives to come out of the roundtable was a government commitment to increase resources for the Comité d’Indemnisation des Victimes des Essais Nucléaires, or CIVEN, a commission established in 2010 to evaluate compensation claims for civilian and military personnel who staffed the test sites. Over its first five years of operation, CIVEN approved only 2 per cent of claims. Changes to the law since 2017 have improved the compensation process, but political and community leaders in French Polynesia continue to push for further reforms.

In June, Moetai Brotherson put forward draft legislation to the French National Assembly seeking support from Macron’s La République En Marche party to increase funding to French Polynesia’s Caisse de Prévoyance Sociale, or CPS, the fund that provides medical pensions and social security for French Polynesians. Pledges at the July roundtable mean little, he says, alongside the brusque rejection of this legislation.

“I had a law proposal that tried to encompass the main requests from the victims, the associations and our CPS social security system,” says Brotherson. “I worked for two years on this proposal that was presented on 17 June. But of course it was dismissed by the majority here.”

Patrick Galenon, the former CPS chair, joined the Reko Tiko delegation at this month’s roundtable. Speaking to journalists in Paris, he highlighted the striking burden of cancer facing many Polynesians: “According to our CPS data, Polynesian women aged between forty and fifty years old have the highest rate of thyroid cancer in the world.” Back in Tahiti, Galenon says he was disappointed by how the discussions unfolded: “We have provided the French state with a lot of data concerning the situation of CPS, how the twenty-three radiation-induced diseases have cost the community more than eighty billion Pacific francs since 1985.”

Today, the French Polynesian government is seeking reimbursement of this massive A$1 billion cost. Community organisations are also calling for France to fund research into the possible intergenerational impact of radiation on the children and grandchildren of Mäòhi workers who staffed the test sites.

Medical researchers want more resources to track the burden of cancer among French Polynesians. Earlier this year, the French medical research agency Inserm released a major report on the health impacts of the nuclear testing program and called for a more comprehensive cancer register in Tahiti and better documentation of cardiovascular and congenital abnormalities among French Polynesians.

Will President Macron use his visit to recommit to the pledges by successive governments over many years? Moetai Brotherson worries that “the message delivered by Emmanuel Macron when he comes to Tahiti will have very little to do with the Polynesians — in fact, it will have much more to do with the interests of France in the region.” •

Reporting for this article was supported by a Sean Dorney Grant for Pacific Journalism through the Walkley Public Fund.

The post Macron, memory and Moruroa appeared first on Inside Story.

Despite the disruption, the company’s chairman and chief executive, James Quincey, was optimistic. Twice he told the investors that history showed the company would emerge stronger from the crisis. “While there are still many unknowns ahead, we do know that over our 134 years of business we’ve seen many types of crisis, be they military, economic, or pandemic, and the Coca-Cola Company has always emerged stronger in the end,” he said.

The transcript of the call also records that the investors on the line — representing Deutsche Bank, Goldman Sachs, Barclays Capital and other companies — were told how Coca-Cola was supporting relief efforts in “markets impacted across the globe.”

Coca-Cola is not the only company to have looked for opportunities during the pandemic. When public health advocates put out a call last July for examples of unhealthy industries seeking to capitalise on the disruption, they received several hundred documented examples from more than ninety countries.

These showed how alcohol, tobacco, fossil fuel, gambling and ultra-processed food companies had used the pandemic to promote corporate goals, whether through marketing and sales, influencing government policy, or generating positive publicity using philanthropic and other “corporate social responsibility” initiatives, or CSRs. (The latter have less flatteringly been dubbed “crisis washing.”) The pandemic has created new opportunities for companies to meet with politicians and policymakers by positioning themselves as partners of governments, health agencies and charities.

These findings come in a report, Signalling Virtue, Promoting Harm: Unhealthy Commodity Industries and COVID-19, published jointly last year by the NCD Alliance, an international network that seeks to improve how governments prevent and control non-communicable diseases, and SPECTRUM, a multi-university, multi-agency British research consortium.

A “striking theme” in the submissions, the report says, was how often unhealthy industries sought to associate their products with the work of health professionals, emergency services and other frontline workers during the pandemic. Philip Morris International donated fifty ventilators through its Greek subsidiary to intensive care units in Greece, for example. Other tobacco and alcohol companies made donations, including medical equipment and personal protective equipment, to Red Cross organisations in many countries.

In the United States, a McDonald’s campaign offered healthcare workers a free “thank you meal” if they shared a selfie of themselves with the meal. For each selfie, the franchise promised a meal coupon to the local food bank. In New Zealand, the United States and Britain, Krispy Kreme offered free doughnuts to healthcare and other frontline workers. In Russia, Heineken’s local subsidiary donated meals and its energy drink to doctors and nurses on night shift. In Adelaide, Lifeline used social media to thank Red Bull Australia for the “surprise delivery [of energy drinks] to help keep our Crisis Supporters energised as they answer calls for support.”

Several companies referred to their Covid-19 response in specially branded products and promotions. In China, a partnership between PepsiCo and the People’s Daily led to the release of limited edition newsprint-style soft drink labels celebrating health workers, scientists and hospital builders. In Mexico, Coca-Cola quickly produced gracias cans and bottles listing workers involved in the Covid-19 response. In Canada, a Subway fast-food franchise offered a free face mask with every two sandwiches purchased in a deal advertised as a great way to “protect you and your kids.” Alcohol companies in several countries created branded masks.

Marketing by infant formula companies in Vietnam, Cambodia and China capitalised on parents’ pandemic anxieties, including by promoting the “alleged immune-boosting potential of milk formula.” In France and Britain, food giant Danone produced ads targeting concerned parents of babies “born into the pandemic,” which directed parents to a “support and information” site hosted by their Aptamil brand. In Mexico, Nestlé, YSA Pharmacies and FEMSA, the country’s Coca-Cola bottler, breached the International Code of Marketing of Breast-milk Substitutes by offering to “gift” formula to vulnerable families for every can of infant or toddler milk purchased.

The Signalling Virtue report contains many more examples and warns that its findings “raise concerns about the prospect of a corporate capture of Covid-19 in which the involvement of unhealthy commodity industries in the pandemic response risks directing public policy efforts away from broader health and social goals and towards the entrenchment of industry interests.”

Lucy Westerman, an Australian who lives in England’s Midlands, was one of the report’s co-authors. When she presented its findings to the recent Preventive Health Conference 2021 in Perth, she described one example of marketing that she found “particularly tasteless.” In Brazil, brewer Karsten created a graphic in the style of their logo to resemble a pair of lungs, with the slogan “Good beer is like air: you can’t live without it,” and encouraged consumers to follow three key tips to survive with Karsten — isolate, use sanitiser and drink beer for fun.

Westerman tells me she is alarmed that companies whose products contribute to the rising incidence of cardiovascular and respiratory disorders, diabetes, dementia and other non-communicable diseases have sought to position themselves as part of “the solution” to the pandemic, given that people with those conditions are at increased risk from Covid-19.

Globally, about forty-one million people die each year from these diseases, many of which are associated with ultra-processed foods, alcohol and other unhealthy products. Just this week, the Financial Times revealed that an internal Nestlé report had acknowledged that more than 60 per cent of the company’s mainstream products wouldn’t meet a “recognised definition of health” and “some of our categories and products will never be ‘healthy’ no matter how much we renovate.”

“It’s been quite astonishing to watch it all play out,” says Westerman of the companies’ pandemic strategies. “These behaviours are not unfamiliar; they are things we see anyway. But what we notice is that it was amplified; the pivoting was so rapid right at the beginning of the pandemic. The industries start literally saying, ‘We are part of the solution.’”

On a more positive note, Westerman also points to how the pandemic has helped increase awareness of these diseases’ toll, with some governments stepping up efforts to tackle their causes. Some Mexican cities have banned the sale of junk foods to children, while the British government is taking serious steps to tackle obesity and South Africa has restricted tobacco and alcohol sales during lockdown.

“Covid has been an absolute wake-up call,” says Westerman. “I think governments are now aware of how unhealthy their populations are; in that first wave, most of the people who died had underlying conditions like obesity and diabetes. If we’ve learnt anything from this pandemic, it’s that we can no longer allow vested interests to get in the way of sound health promotion policy.”

Similar concerns about the alcohol industry’s efforts to exploit the pandemic were raised in An Alcohol Ad Every 35 Seconds, a report released last year by the Foundation for Alcohol Research and Education, or FARE, and Cancer Council WA. It found that the marketing messages used during the pandemic have encouraged people to buy more alcohol, drink to cope, drink daily and drink at home or alone. Caterina Giorgi, FARE’s chief executive, tells me that the industry has also used the pandemic as an excuse to press for favourable policy changes and lobby against regulation. Yet the pandemic has also underscored the need for measures to reduce the lobbying power of the industry.

Reducing the tobacco industry’s influence is the aim of the World Health Organization’s Framework Convention on Tobacco Control, ratified by 180 countries and the European Union, which spells out how governments should protect their public health policies from commercial interests. Its implementation guidelines recommend that governments “denormalise and, to the extent possible, regulate activities described as ‘socially responsible’ by the tobacco industry, including but not limited to activities described as ‘corporate social responsibility.’”

Yet the pandemic has created new opportunities for the tobacco industry to expand its reach and influence, including through its CSRs, especially in countries that have not ratified the treaty.

One of these countries is Indonesia, where public health researcher Putu Ayu Swandewi Astuti has been keeping a close watch on tobacco industry activities since the earliest days of Covid. She has documented an upsurge in online promotions and pandemic-related marketing, and tracked how the industry has provided support to governments and the health sector, including by donating protective equipment and other supplies.

Astuti, from Udayana University in Bali, says governments need to develop a greater understanding of how the industry uses CSRs to promote its goals. They should also launch public health campaigns advising smokers that the pandemic is an ideal time to quit.

The strategies Astuti has documented in Indonesia are also being used more widely, according to the Global Tobacco Industry Interference Index 2020, a report by the Thailand-based Global Center for Good Governance in Tobacco Control. It says Philip Morris International reported donating “over US$32 million across sixty-two markets in the first few months of the pandemic.” The company’s CSR activities included distribution of ventilators to Czech Republic, and hand sanitisers to Brazil, Indonesia, the Netherlands and the Philippines. The Indian Tobacco Company used its Savlon brand to partner with the Kerala state government on a statewide handwashing campaign called “Break the Chain.”

In April, British American Tobacco’s Kenyan subsidiary contributed 300,000 litres of sanitiser to government agencies. And although Kenyan government officials aren’t permitted to accept donations from the tobacco industry, they did accept an industry donation to the president’s Covid-19 Emergency Response Fund.

“While publicising its charitable acts,” the report says, “… the industry was simultaneously lobbying governments not to impose restrictions on its business and even to declare tobacco as an ‘essential’ item during the pandemic.” Three days into Jordan’s complete lockdown, when the government commissioned city buses to deliver bread and other essentials, the labour minister announced the government would add cigarettes to the list. Tobacco consumption rose by more than 50 per cent among Jordanians during the lockdown. Kenya also listed tobacco as an essential product during the pandemic, which meant providers had protection and special permits to transport during the lockdown.

For Becky Freeman, a public health researcher at the University of Sydney and a long-term investigator of the tobacco industry, the tactics used during the pandemic, while shocking, are not surprising, and underscore the importance of countries’ implementing the WHO guidelines.

She says the widespread use of “crisis washing” shows how vital it is that pandemic responses include efforts to rein in non-communicable diseases, rather than maintain the “artificial separation” between non-communicable diseases and communicable conditions like Covid-19. “We need to ensure populations are as healthy as possible for when the next pandemic comes along.”

For this to happen, public health researchers need to tackle the political and economic power of ultra-processed food corporations more effectively, suggests an important new paper by researchers from Australia, Brazil and Indonesia, which outlines how the industry is driving the “pandemics” of obesity and diet-related non-communicable diseases.

The authors suggest it would be more appropriate to refer to them to as “supranational corporations” because their “size, power, global reach, and capacity” allow them to circumvent countries’ laws and regulations, “effectively allowing them to operate ‘above’ the nation state.” These corporations can “avoid or reduce payment of corporate tax. This in turn reduces the capacity of the government to finance health services and programmes, and the public health system’s capacity to prevent and treat non-communicable diseases,” they write.

Indonesia’s experiences demonstrate such companies’ impact on health. The researchers note that “over the last three decades, Indonesia has undergone a profound socioeconomic and epidemiological transition,” with seven out of ten Indonesian deaths now related to non-communicable diseases and dietary risks being one of the three leading factors. “Between 1999 and 2014, Indonesians’ caloric intake of pre-prepared and packaged food nearly doubled.”

Big Food has undertaken many CSR activities in Indonesia. Nestlé, for example, has partnered with schools and non-government organisations through its Nestlé Healthy Kids program, and distributed 1.6 million food and beverage products during the pandemic. The researchers report that Coca-Cola Amatil Indonesia and Mondelez Indonesia also have “significant CSR projects to strengthen their relationships” with the government, local charities and religious institutions.

Tackling such powerful industries, say the authors, will require new collaborations with political strategists, lawyers prepared to fight for people’s health, and strategists who understand how to use digital media to advance health.

The Signalling Virtue report stresses the importance of seeking to “build back better” rather than succumbing to industry pressure to adopt approaches to taxation, trade and regulation that have long proven damaging to health and development.

Coca-Cola chief executive James Quincey is also a director of Pfizer, one of the pharmaceutical companies lobbying hard against moves to waive the international treaty on Trade-Related Aspects of Intellectual Property Rights. The proposed waiver seeks to ensure equitable access to Covid vaccines, which is not only morally right but also essential for global pandemic control.

Last year Sandro Demaio, the chief executive of VicHealth, pinned a tweet to his Twitter home page saying: “To give some perspective on the incredible work of the World Health Organization. They eradicated smallpox, worldwide. Their entire global budget is about half what Nestlé spends on advertising each year. 7000 staff work for WHO worldwide. Kmart has 34,000 staff in Australia.”

As the World Health Assembly wound up on 31 May, WHO director-general Tedros Adhanom Ghebreyesus issued a pointed call for governments to alleviate the organisation’s longstanding funding constraints. “The message that a strong WHO needs to be properly financed has been amplified by all the expert reviews that reported to this Assembly,” he said.

The pandemic, it seems, has exposed the life-threatening power imbalance between the private and public interests that shape our health. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

The post The twin pandemics appeared first on Inside Story.

The report deals with four possible ways the SARS-CoV-2 virus might have emerged and infected people in Wuhan. Its “likely to very likely” scenario is that the virus was transmitted to humans from an original source (almost certainly bats) by an intermediate animal host. Direct transmission from the primary animal source (referred to as zoonotic spillover) is “possible to likely.” A “possible” route would have involved transmission via frozen foods — viable viruses can be carried long distances on frozen food packaging — but an escape of the virus after a laboratory incident is seen as “extremely unlikely.”

While political sensitivities help explain the report’s tentative language, scientists, epidemiologists and public health officials weren’t surprised by its inconclusive findings. Making definitive judgements on this sort of question is never easy. AIDS, for instance, was first identified in the 1980s in the United States but it was not until 1999 that researchers could say for certain that the causative virus, HIV, originated from the simian immunodeficiency virus in monkeys, with chimpanzees as the intermediate hosts.

Even with advances in genomics since then, it would be unusual for a report twelve months into a pandemic to provide answers to all the key scientific questions. The team that produced the WHO report describe it as “a first start” and “not a static product but a dynamic one.”

The report’s first scenario reflects the generally shared view of infectious disease experts. The same route was followed by the coronavirus that caused SARS in 2002 (from bats to human, probably via raccoon dogs or civets) and Middle East respiratory syndrome in 2012 (where the likely intermediary was camels).

Although the first official case of what came to be called Covid-19 was recorded in Wuhan on 8 December 2020, it wasn’t until 21 January that Chinese authorities conceded the disease could spread by human-to-human transmission. The standard international response to an emerging public health problem, under the auspices of the WHO, was perhaps slow to get under way, but by late February 2020 the organisation had issued the report of a joint mission with China. Its goal was to underpin pandemic planning in China and internationally. The following month a brief report summarised what was then known about the origins of SARS-CoV-2 from an ongoing global study coordinated by the WHO, and the WHO also made recommendations to reduce the risk of other pathogens emerging from animals to humans in markets like Wuhan’s.

Then Donald Trump intervened, and everything became much more chaotic and increasingly driven by politics rather than science.

With a tweet on 16 March, Trump began referring to the coronavirus as the “Chinese virus.” His initial attack reportedly came after a Chinese foreign ministry spokesperson speculated that the American military personnel who attended the Military World Games in Wuhan in October 2019 could have introduced the virus.

The rhetoric quickly escalated. Soon Trump and the American right-wing media were repeatedly blaming China for the contagion, stating that it could have done more to prevent the disease spreading and proposing that the source of the virus might be a Wuhan research laboratory. As a counter, China suggested that the virus existed abroad before it was discovered in Wuhan and may have been imported into the country on or in frozen foods.

Trump also conflated blaming China with his hostility towards the WHO. He had already acted to withdraw the United States from the organisation and he now claimed the organisation had an “alarming lack of independence” from China.

Australia was drawn into the political fray in April when prime minister Scott Morrison put forward a three-point plan for overhauling the WHO: redefining its formal powers; recruiting independent investigators who would determine the source of major outbreaks like the current pandemic; and creating an independent review body to examine the performance of the WHO during such crises. Predictably outraged, the Chinese government accused Australia of launching a political attack on China and “pandering” to the United States. The furious backlash included a series of attacks on Australian exports.

Morrison wasn’t necessarily doing Trump’s bidding, but his efforts implicitly acknowledged that broad international support for a US-led inquiry was highly unlikely. As it turned out, Australia’s chances weren’t much better, although Morrison has sold the outcome as a win. Despite some heavy lobbying by Morrison, foreign minister Marise Payne, and Australia’s WHO representative Lisa Studdert, Australia’s plans were ultimately watered down considerably by the World Health Assembly, the WHO’s decision-making body.

The compromise was found in a motion from the European Union that called only for an “evaluation” of the outbreak by one of the WHO’s internal independent review committees. The motion — passed in May by the World Health Assembly with 137 votes, including from China, the United States and Australia — made no specific mention of China and provided no new powers for the WHO.

Enter the WHO origins study, whose delayed report was released last week. This is a separate process from the arm’s-length independent evaluation panel, chaired by former New Zealand prime minister Helen Clark and former Liberian president Ellen Johnson Sirleaf, which will report to the World Health Assembly, the WHO’s governing body, at its May session.

It wasn’t until November that Beijing and the WHO agreed on a series of scientific studies to be carried out in China. (These, together with the composition of the study team, were promptly rejected by the Trump administration.) The two primary aims were to determine exactly when the outbreak started and to learn how it emerged and jumped into the human population. Three types of data would be vital: genetic sequences of the virus, tests on animals, and epidemiological research into the earliest cases.

When the foreign members of the investigative team visited Wuhan in January through February, it was to help in a joint assessment of the evidence that China had found, not to scour the city for new facts. Indeed, the foreigners weren’t free to wander. While they were able to visit all the places they had requested, each visit was carefully managed. One WHO team member called the Wuhan trip a “highly chaperoned, highly curated study tour.”

Partly as a result, the report leaves unanswered a number of questions — some of them contentious — and raises other issues that need to be tackled. Where, for instance, are the bat population that harboured the progenitor of the SARS-CoV-2 virus and the intermediate host/s and what was the conduit of the virus to Wuhan? A coronavirus very similar to SARS-CoV-2 is found in the horseshoe bats that live in caves hundreds of kilometres from Wuhan, but these bat viruses don’t have a specific binding domain that would enable the spike protein to attach to a receptor on human cells, thus initiating the disease process. The important binding domain is believed to have emerged in the intermediate host. Scientists have so far tested more than 50,000 samples from domestic, farm and wild animals in the Wuhan region looking for potential intermediate hosts, and have found no trace of the virus that causes Covid-19.

Much more work is needed to explore the possibility that animal-breeding farms in southern China may be disease reservoirs. Once heavily promoted by the government, many or most of the wildlife farms appear to have been shut down in February 2020 — a strong signal that Chinese authorities considered them a probable pathway for a coronavirus to reach humans. While SARS-CoV-2 has been found in domestic cats, dogs and ferrets, in captive lions and tigers, and in farmed mink in Europe, this is a result of transmission from humans, known as reverse zoonosis. But mink, fox and raccoon dog are raised for fur in China and have not yet been eliminated as intermediate hosts.

The investigative team called for more studies of the possible role of frozen wildlife in viral transmission, and whether and how people can be infected through this route. It also recommended broadening the search for the virus’s origin beyond China. Recent reports of coronaviruses closely related to SARS-CoV-2 being found in bats in Japan, Cambodia and Thailand would justify this move, according to scientists.

The Chinese members of the team appeared to strongly favour the hypothesis that the virus could have reached Wuhan on a frozen food shipment — the third of the WHO report’s scenarios — especially if this indicated that the virus came from outside China. China has tested 1.5 million frozen samples and found the virus thirty times, so this scenario can’t yet be ruled out.

Of course, where a disease is first reported isn’t necessarily where it started. Recent evidence suggests that the first case of Covid-19 in Hubei province can be tracked back to 17 November 2019, and that by 20 December sixty cases had been confirmed. If this is correct, then either those cases were not detected or recognised at the time, or they were detected and recognised but reporting was suppressed.

Genetic evidence supports this timeline. Using molecular dating tools and epidemiological modelling, scientists estimate that the virus was circulating for about two months prior to December 2019. Add to that the growing evidence that the Wuhan market, while it may have harboured a viral “superspreader,” was not the source of infection.

Efforts in Wuhan and nearby areas to track down the earliest cases should continue, the WHO team said, to help researchers understand how the pandemic started. It recommended analysing older samples from blood banks in the province, though it isn’t clear who would provide the required technology, staffing and funding to undertake this effort.

The fourth of the WHO scenarios — a laboratory release, accidental or deliberate — may be unlikely but is still being propagated by the likes of former US secretary of state Mike Pompeo and, surprisingly, even the former head of the US Centers for Disease Control and Prevention. Until this possibility can be definitively dismissed, it will continue to undermine relations between China and countries like Australia and the United States.

The Wuhan Institute of Virology has certainly analysed bat viruses, and it does possess gene information about coronaviruses that it has not released publicly. China has a history of disinformation and delays in reporting about SARS-CoV-2 that serve to heighten suspicions. And laboratory accidents and safety lapses do happen. In an open letter published in the Wall Street Journal and Le Monde in March, a group of scientists argued that flaws in the joint WHO–China inquiry meant it couldn’t adequately explore the possibility the virus leaked from a laboratory.

Ironically, the Trump administration last May pulled the funding provided through the National Institutes of Health for a decade-old joint research alliance between American scientists and Chinese scientists at the Wuhan Institute of Virology, which was studying coronaviruses in bats and their spillover into humans. The consequent loss of trust and access was surely a hindrance to the WHO inquiry just a few months later.

Almost immediately after the report’s release, a number of countries expressed deep concerns about the adequacy of the findings. In a joint statement, Australia, the United States and twelve other countries said that the WHO team hadn’t had access to all the information it needed in China. White House press secretary Jen Psaki said that President Biden believes Americans “deserve better information” about the origin of Covid-19. The WHO report “doesn’t lead us to any closer of an understanding or greater knowledge than we had six to nine months ago about the origin,” she added. “It also doesn’t provide us guidelines or steps on how we should prevent this from happening in the future.”

Perhaps it was these concerns that prompted the WHO director-general Tedros Adhanom to remark during a briefing to member states that the report hadn’t made an “extensive enough” assessment of the possibility the virus was introduced to humans through a laboratory incident. Further data and studies will be needed to reach more robust conclusions, he said, adding that he expected “future collaborative studies to include more timely and comprehensive data sharing.”

The key participants must ultimately acknowledge that the point of these investigations is not geopolitical advantage but a better understanding of how the SARS-CoV-2 virus came to be so damaging. Despite what Trump and perhaps other leaders think, the aim of such investigations is not to apportion blame; if this becomes the key driver, they will never succeed.

Dominic Dwyer, an Australian infectious diseases expert who was part of the team that went to Wuhan, made the point well when he said, “Rather than blaming governments, we need to foster cooperation and trust between investigators, between and within countries. This not only helps us during this pandemic; it’s the key to managing future pandemics. The more cooperative we are, the more likely we are to get the best results. We have to make sure politics doesn’t muck that up.” •

Funding for this article from the Copyright Agency’s Cultural Fund is gratefully acknowledged.

The post In search of ground zero appeared first on Inside Story.

Global consultancy Stratas Advisors recently ranked Australia’s fuel quality as eighty-fifth in the world — between Argentina’s and Tanzania’s — on the basis of its high proportion of sulphur, a key health and environmental toxin. This is a worse ranking than all European countries, the United States, Canada, Japan, China and India, and most other countries in the Asia-Pacific region, including Singapore, Malaysia, the Philippines, New Caledonia, Fiji and New Zealand.

Australia’s poor fuel is well known internationally and recently became an issue in negotiations over the EU–Australia free trade agreement. Some car manufacturers refuse to supply certain of their new models to Australia or to downgrade the engines of cars designed for the cleaner fuel available in Europe, because of the risk of damage from our low-quality petrol.

And yet, when the regulations in the Fuel Quality Standards Act 2000 were reviewed in 2019, the federal government ignored calls from health experts and organisations to bring Australia’s fuel standards into line with best overseas practice. Expert advice was trumped by opposition from Caltex, Mobil, Viva Energy and BP, the oil companies that make up Australia’s domestic oil refining sector.

The Global Burden of Disease Study says that one of its “most alarming” findings is that “about a third of the burden of stroke is attributable to air pollution.” Air pollution is known to damage the lungs, heart and brain, it says, but “the extent of this threat seems to have been underestimated.”

Australian-based research, including the landmark Australian Child Health and Air Pollution Study, has demonstrated that even low levels of exposure to air pollution can increase the severity of asthma among children. A study recently published in the European Respiratory Journal found that Australians aged forty-five to fifty who live less than 200 metres from a major road have a 50 per cent higher risk of asthma, wheeze and lowered lung function over a five-year period than those who live further from a major road.

Lung cancer is another well-documented effect of air pollution. But newer research has demonstrated causal links between air pollution and other forms of cancer, such as pancreatic, colorectal and bladder, as well as increased mortality from all cancers. Emerging research is also demonstrating a link between air pollution and obesity, Alzheimer’s disease, dementia, Parkinson’s disease, allergic reactions and ADHD.

Perhaps the most serious impact of air pollution is on the brain and respiratory-system development of babies in utero. The link between premature birth and air pollution has been known for some time, but reports of a dramatic drop in pre-term births during the Covid-19 pandemic have led some researchers to speculate that reduced exposure to air pollution may be part of the reason. Evidence even suggests that exposure to air pollution can cause DNA changes that can then be passed on to future generations.

Despite all this evidence, public awareness of the dangers of air pollution remains low. This partly reflects the fact that the harms of air pollution can be difficult to spot at the individual level. Like smoking, air pollution increases an individual’s risk of serious conditions. Identifying the population-wide harms of air pollution means extrapolating data from large-scale epidemiological studies that clearly demonstrate the link between air pollution and serious health conditions.

Using 2017 data, the Clean Air and Urban Landscapes Hub and the Melbourne Energy Institute put the Australian health costs of air pollution each year at $17.8 billion, with an additional $4.5 billion in “welfare losses and foregone labour output.” On those figures, air pollution’s health costs are greater than those of obesity ($11.8 billion in 2017–18) and close to those of smoking ($19.2 billion in 2015–16).

Not only are motor vehicles Australia’s third-largest source of greenhouse gas emissions, they also have a greater direct impact on health than the same level of emissions from other sources — factories, for example — because of higher levels of exposure in the population.

According to the State of Global Air report, the small particulate matter (PM2.5) produced by vehicle emissions was responsible for an estimated 1715 premature deaths in Australia in 2015, more than the annual road toll. (Other harmful components of vehicle emissions are not included in this figure, and nor are coal-fired power stations, factories, wood-burning heaters and other causes of air pollution.) The International Council on Clean Transportation estimates that reducing toxic materials in vehicle emissions could cut premature deaths by around 75 per cent.

Sulphur in fuel increases the production of sulphur dioxide, nitrous oxides, carbon monoxide and other toxic gases. It also creates harmful small particulate matter that can be inhaled and can enter the bloodstream. Fuels high in sulphur also prevent the effective operation of emissions control technology, such as particulate filters, which is why car manufacturers including Volkswagen (anxious to regain its reputation after an earlier fuel scandal) will not sell their most eco-friendly cars in Australia.

Clare Walter, a PhD candidate researching air pollution and policy at the University of Queensland, says the move to low-sulphur fuel would have the dual benefit of supporting the uptake of vehicles with the most advanced emission controls while reducing toxic emissions from Australia’s current fleet.

“Our current standards are in line with those introduced in Europe in 2009 — they are known as Euro 5,” Walter tells me. “Australia did not mandate these standards until 2016, by which time Europe had moved onto more stringent standards, Euro 6.”

Why that laggard status has persisted is a case study in how clear medical evidence can be outweighed by well-organised and well-resourced industry lobbying. Despite extensive evidence of the harms of air pollution, a five-year government review into Australia’s fuel standards concluded in 2018 by recommending no changes to fuel quality until 2027.

The process began with the release of a discussion paper on vehicle emissions in December 2016, by the then environment minister (now health minister) Greg Hunt. “Around 17 per cent of Australia’s greenhouse gas emissions are from transport,” he said bluntly. “In cities such as Sydney on-road motor vehicles can contribute around 60 per cent of some noxious air pollutants.” The following year, his successor as environment minister, Josh Frydenberg, declared that “Australia’s petrol quality is the lowest in the OECD or seventieth in the world.”

Hunt’s discussion paper contained five options:

A. No change in Australia’s fuel standards (maximum allowable sulphur content in standard petrol remains 150 parts per million, or ppm).

B. Harmonisation with European standards within two to five years (low grade petrol phased out, maximum sulphur in premium unleaded petrol limited to 10 ppm).

C. As with option B, but low-grade petrol retained (maximum allowable sulphur content 10 ppm)

D. Harmonisation with the (stricter than Europe) standards recommended by the Worldwide Fuel Charter (maximum allowable sulphur content 10 ppm)

E. A gradual improvement in quality standards from 2020 with a review in 2022 (maximum allowable sulphur content for standard petrol 50 ppm) heavily favouring a reduction in sulphur levels to 10 ppm, the maximum allowed in most other developed countries.

Submissions from health and environmental groups strongly supported the options that would bring Australia’s fuel standards in line with Europe, most other developed countries, and even the United States — option B or, failing that, D.

But the government’s subsequent draft regulation impact statement added a sixth option suggested by the downstream petroleum sector, represented by the Australian Institute of Petroleum, which involved no action on sulphur until 2027. The institute argued that the refining industry would need to invest around $979 million, “which may threaten the economic viability of the remaining refineries in Australia,” and stressed that the price of petrol could rise as a consequence — two possibilities that no doubt influenced government decision-making.

Robyn Schofield from the School of Earth Sciences at the University of Melbourne is one who challenges the institute’s argument. All the Australian refiners are multinational and operate in jurisdictions requiring a maximum 10 ppm of sulphur, she says. There is no reason they can’t bring the same technology to Australia.

Schofield also argues that the cost of upgrading refineries is outweighed many times over by the health costs associated with increased mortality and morbidity caused by poor fuel quality. If the government is concerned about potential petrol price rises it could fund the upgrade itself, she says, out of the $6 billion per year collected in petrol excise, for example. The cost-effectiveness of such a move would be incontrovertible given that the cost of the $979 million upgrade would be significantly lower than the $17.8 billion in annual health costs associated with vehicle emissions.

The Institute of Petroleum also argues that the generally good quality of Australia’s air undermines the case for improving fuel standards. Not so, responds Clare Walter. “Average” measures of air quality are not an accurate representation of the risks of exposure to pollution in specific locations and among specific populations. “The air-quality models used in the government’s analysis were designed to reflect regional air quality rather than roadside air-quality conditions,” she says. “Yet much of our population lives in big cities and spends a considerable amount of time exposed to roadside pollution.”

We also need to recognise exposure among people at higher risk from air pollution, such as young children, people with respiratory conditions and the elderly, says Walter. She also questions the validity of calculating health risks based on international epidemiological studies that use finer-grained data from overseas.

Health groups contend that the calculations used by the government in assessing the cost-effectiveness of different policy options fail to take account of Australia’s underlying population health. Asthma and allergies are more prevalent here than in the United Sates and EU countries, for example, making our population more vulnerable to air pollution.

None of these or other points made by health organisations appear to have been considered by the government. Health groups and experts were limited to providing written submissions to the regulatory review process, and were then largely ignored. The review’s “stakeholder forums” and face-to-face meetings almost exclusively involved industry representatives and were dominated by the Australian Institute of Petroleum. Even high-profile government-funded organisations — the Clean Air and Urban Landscapes consortium, the Clean Air Society of Australia and New Zealand, the Centre for Air Pollution, Energy and Health Research, or CAR, and peak bodies in air, energy and health research — were excluded from full participation.

The experience of Graeme Zosky, an expert on the health impacts of air pollution who was the lead author of CAR’s submission, was typical. As deputy director of the Menzies Institute for Medical Research and a professor of physiology at the Tasmanian School of Medicine, he recalls being contacted by a consultant for input on the evaluation measures for the policy options. But he wasn’t invited to any of the stakeholder forums or interviewed by the department.

Also lacking has been any health-sector representation on the two major committees with a role in fuel standards. The health minister isn’t among the members of the Ministerial Forum on Vehicle Emissions, which is responsible for coordinating the government’s regulation of motor vehicle emissions, and the health department is not represented in its secretariat.

Interestingly, the forum’s influence on policymaking is hard to gauge because details of its meetings are not publicly available — a lack of accountability highlighted by senator Rex Patrick when he questioned a representative of the Department of Infrastructure, Regional Development and Cities during a Senate inquiry hearing in August 2018:

Senator Patrick: I presume the ministerial forum produces minutes.

Mr Foulds: No, they don’t produce minutes as such…

Senator Patrick: Do you have officials go along that take notes?

Mr Foulds: The forum has met without officials and with officials.

Another key advisory group on fuel standards is the Fuel Standards Consultative Committee, whose members include representatives of all states and territories, the Commonwealth, fuel producers, an environment protection body and a consumer interest body, but no health expert or representative of the health sector. The minister is required to consult the committee before creating or amending a fuel quality standard.

The lack of health-sector involvement in these two committees and their secretariats probably contributed to the focus on the oil industry’s perspective rather than health impacts in the final regulation impact statement, released in August 2018. The statement includes an analysis of policy options B, C and F (the industry’s option) relative to the status quo (option A), based on the following criteria:

1. Achieve appreciable health and environmental outcomes
2. Ensure the most effective operation of engines
3. Facilitate adoption of better engine and emission control technologies
4. Achieve harmonisation with European standards, as appropriate
5. Minimise regulatory burden
6. Maximise net national benefits.

The analysis demonstrated that option F only partially met the first criterion: appreciable health and environmental outcomes. It also showed that option B was the only one that would decrease greenhouse gas emissions.

The final regulatory impact statement concedes that option B was supported by approximately 60 per cent of submissions because it would deliver maximum health and environmental benefits. It also states that the proposal to reduce sulphur to 10 ppm was “supported almost unanimously — only one submission (confidential) expressed a preference to maintain current levels of sulphur in petrol.”

Yet the statement opts for the industry’s option F on the basis that it avoids the cost of upgrading oil refineries. It also makes clear that this was the option supported by the downstream petroleum sector. In relation to sulphur, the statement says that delaying any reduction until 2027 is the “best option for the viability of domestic refineries” and therefore “the best option from a system-wide perspective.”

Health experts’ detailed criticism of the methodology used to determine cost-effectiveness is not covered in the statement; instead, it focuses almost exclusively on the positions of the Australian Institute of Petroleum and other industry organisations. Tellingly, its summary of “key views from stakeholders” fails to mention any of the health and environmental groups that provided feedback on the policy options.

Following the publication of the final regulatory impact statement, the new fuel standard regulations were introduced into parliament last year.

The failure of the standards review to improve Australia’s fuel quality shows how interest groups with deep pockets can dissuade governments from making changes that reflect expert advice and promote public health. That influence explains why Australia lags behind most other developed countries in reducing the level of toxic material produced by our seventeen million cars, even though 90 per cent of Australians live in urban areas and are directly affected by vehicle emissions.

The implications for dealing with other threats to public health, such as climate change, obesity, poverty and inequality, are obvious.

One of the most frustrating aspects of this issue, according to Robyn Schofield, is that Australians “have been lulled into a false sense of security and don’t understand that these standards are being dictated by the petroleum industry.” Add to this the fact that improving fuel quality is relatively simple compared with other strategies to reduce air pollution, such as phasing out coal-fired power. Schofield describes better standards as potentially an “easy public health win” that should be a “no brainer” for governments.

At the very least, as the Clean Air and Urban Landscapes consortium suggested in its submission, the health department should be included formally in developing fuel standards. The Heart and Stroke Foundations and other public health groups could play an important role from outside by using their profile and lobbying expertise to support scientists taking on a greater advocacy role. In contrast with both the American and British Heart Associations, neither of these organisations currently takes a position on the health impacts of air pollution.

Australia has relied on high-quality scientific and medical expertise to steer us through the Covid-19 pandemic. But we don’t have a good track record in supporting research scientists outside crises. The lag between public health research findings and policy changes can be significant: it took twenty years from the discovery of the health harms of smoking until the first health warnings appeared on tobacco products, and another twenty years before tobacco advertising was banned.

We shouldn’t have to wait forty years for action on fuel quality. But history shows that overcoming the influence of well-resourced interest groups and the inertia of governments and entrenched bureaucratic cultures won’t happen without a struggle. •

The post Fuel’s paradise appeared first on Inside Story.

I am still to detect a serious commitment to community participation in Australia’s Covid-19 response. Instead we get premiers and prime ministers fronting press conferences with today’s mix of empathetic motivational exhortation and stern warnings that police are out there fining miscreants. Little surprise, then, when ludicrous adult-toddler tantrums in shopping centres go viral.

This is not the way to foster sustained behavioural change. For that, a web of information, mutual expectations and, above all, self-policing has to be woven from the ground up, sensitive to all the nuances and complexities of the geographies, cultures and histories that make up local communities and contribute to particular risks in particular situations.

What is clear by now is how good the virus is at sustaining itself by transmitting between largely asymptomatic cases. Almost all of the countries that have been congratulating themselves for getting new cases down to zero have been facing renewed outbreaks; this week it was China and Vietnam. European countries, where the virus began circulating in the last months of 2019, well before the public health alerts, have moved through the cycle of overwhelmed health systems, stringent lockdowns, “bending the curve” and reopening, and are now considering which lockdown measures to reintroduce.

Back in February 2020, Harvard epidemiologist Marc Lipsitch was predicting that within a year Covid-19 would infect some 40 to 70 per cent of people around the world. That prediction was something of a double-edged sword — it was accurate as to the virulence of SARS-CoV-2, but it also led to a shrug of inevitability, especially as it was accompanied by the view that most cases would be asymptomatic or mild. Wishful thinkers drew the conclusion that the epidemic was nothing to worry about; more acute observers realised that even if only a tiny fraction of the infected became seriously ill the number of excess deaths would be huge.

Results of surveys estimating what proportion of the population has been infected with SARS-CoV-2 are still all over the place. India’s National Centre for Disease Control recently reported a 23 per cent prevalence in Delhi in early July. Seroprevalence surveys in Geneva showed that less than 5 per cent of the population had antibodies in early April, rising to nearly 11 per cent a month later. Spain has conducted two rounds of a national survey, the latest showing 5.2 per cent prevalence across the country in early June. A modelled estimate of seroprevalence in France was 4.4 per cent on 11 May. New York City reported prevalence rising to between 19 and 22 per cent, and a survey in an informal settlement of Buenos Aires suggested infection rates as high as 53 per cent. Iran’s president recently startled even his own health ministry by announcing that twenty-five million Iranians may have been infected out of a total population of some eighty-four million.

Accurately estimating these numbers is not as easy as it may seem. Serosurveys detect antibodies produced by the infection. The first challenge is to get a representative sample: some of the early HIV prevalence estimates were wildly inflated until it was realised that a sample drawn from those attending STI clinics might not be representative of the whole population. Then there is the accuracy of the tests: do they reliably detect antibodies? And the nature of the antibodies themselves: they are not detectable in the very earliest stages of infection, and in the case of Covid-19 seemingly tend to fade away a few months after infection.

The durability of an antibody response is one of the question marks hanging over vaccine development. The last month saw a number of the most promising vaccine candidates moving into phase 3 efficacy trials. Some of the media coverage presented this as the “final stage” of testing, as if an effective vaccine is nearly here. It would be more accurate to say that the vaccines are just beginning their real test — whether they work to prevent infection — having passed the qualifying hurdles of showing whether they are capable of producing an immune response and won’t kill the recipient. But if the antibody response to SARS-CoV-2 is only transient, then those vaccines that work by producing neutralising antibodies may not produce lasting immunity.

And even if a durably effective vaccine is found — and it would seem that Donald Trump is pinning his re-election hopes on being able to announce one somewhere in the lead-up to polling day — the big issue will be getting access to it.

Globally, three organisations — the vaccine alliance GAVI, the Coalition for Epidemic Preparedness Innovations, and the World Health Organization — have sought to bring order and equity into the scramble for vaccine access through the COVAX facility. More than 150 countries are engaged in the process that aims “to accelerate the development and manufacture of Covid-19 vaccines, and to guarantee fair and equitable access for every country in the world.” Australia has been a supporter of GAVI but was not noted as one of the countries to have submitted an expression of interest in the COVAX facility — unlike New Zealand and Britain, among others. COVAX aims to produce two billion vaccine doses by the end of 2021, delivered equally to all participating countries on a per capita basis, with initial priority for healthcare workers expanding to reach 20 per cent of the population.

COVAX represents planned, fair and orderly access to a future vaccine. The alternative is for the richest countries to make down payments on preferential access. The United States has made a series of announcements of its payments to secure vaccine access, paying Pfizer nearly US$2 billion for one hundred million doses should its vaccine be successful, with an option on 500 million more doses, US$1.6 billion to Novavax for one hundred million doses of its vaccine, and US$1.2 billion to AstraZeneca for 300 million doses of the vaccine it is developing with the University of Oxford. This is on top of the US’s attempt to corner the global supplies of the Gilead-owned drug remdesivir, one of the few Covid-19 treatments to have shown any degree of success.

Meanwhile, Russian state-sponsored hackers have been accused of attempting to steal valuable Covid-19 vaccine information. I am reminded of a UN country team meeting on AIDS a few years ago when a staff member reported with concern that large quantities of the condoms put in dispensers in the toilets had been going missing. The meeting started discussing what sort of locks could be placed on the dispensers, when I intervened: we employ people to distribute free condoms and support all sorts of social marketing exercises trying to get people to buy them; if someone has found a nice little sideline in selling pilfered condoms we ought to be applauding it, not shutting it down. What is the worst the Russians might do? They might develop a vaccine!

Some in the pharmaceutical industrial complex might be salivating at the prospect of making a killing on Covid-19 vaccines. But the de jure and de facto reality is that public health trumps intellectual property rights in a health emergency. The first developers of vaccines will be well rewarded anyway. As soon as an effective product is found, the imperative will be to scale up its production and distribution. •

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France conducted 193 atmospheric and underground nuclear tests in French Polynesia between July 1966 and January 1996. Two and a half decades later, many Maohi (Polynesians) employed at the test sites on Moruroa and Fangataufa atolls are suffering from cancer, skin diseases and other illnesses.

A scheme to compensate civilian and military personnel for the effects of exposure to ionising radiation, named after then defence minister Hervé Morin, was passed by the French parliament in January 2010. The legislation created a new commission, the Comité d’Indemnisation des Victimes des Essais Nucléaires, or CIVEN, to evaluate compensation claims.

Over the first five years of operation, however, CIVEN approved only 2 per cent of claims. Although reforms since 2017 have improved the compensation process, political and community leaders in French Polynesia see recent changes to the law as a step backwards that will significantly restrict access to compensation.

Among those concerned by the latest change is Father Auguste Uebe Carlson, a Catholic priest and president of Association 193, an organisation that mobilises churchgoers in Tahiti around the legacies of the 193 nuclear tests. He believes that health problems in French Polynesia extend beyond the thousands of workers and soldiers who staffed the nuclear test sites.

“The atmospheric tests impacted on all of French Polynesia,” he says. “The French state has difficulty admitting that radiation-induced illnesses have not only affected the Moruroa workers, but the whole population over many generations.”

For decades, French politicians argued that cold war–era testing left no adverse health or environmental legacies. But there is clear evidence of radioactive fallout from French atmospheric tests between 1966 and 1974. Medical researchers have documented significant increases in thyroid cancer, myeloid leukaemia and other illnesses among the Maohi people across the five archipelagos of French Polynesia.

The International Atomic Energy Agency has documented how radioactivity from underground tests leached into the marine environment around the fragile coral atolls between 1975 and 1996. In 1998, the agency estimated that five kilograms of plutonium were dispersed through the sediments of the lagoon at Moruroa atoll.

Today, many people who once supported nuclear testing have acknowledged these hazards. In a stunning statement to the local assembly in November 2018, French Polynesian president Edouard Fritch admitted that successive governments had made false statements about the health and environmental effects. “For thirty years we lied to this people that these tests were clean,” he said. “It was us who lied and I was a member of this gang! And for what reason did we lie? Because our own leader had seen a bomb explode.”

When the Morin Law was enacted, survivors criticised the fact that compensation decisions were ultimately made by the French defence minister rather than an independent decision-maker. They were also angered that Article 4 of the law deemed that there was “negligible risk” of contamination, leaving applicants with the challenge of proving that significant levels of radiation exposure had in fact caused their illness.

Many Maohi workers lacked health records or documentation of their employment at the nuclear test sites, so this provision created a burden of proof that many found impossible to meet. Data released by CIVEN shows that between 5 January 2010 and 15 March 2015, only seventeen of 862 claims were approved from applicants from France, Algeria and French Polynesia.

Since then, protests by political and community groups in Tahiti and France have led to a series of changes. CIVEN has been transformed from an advisory body to the defence minister into an independent statutory organisation with its own chair (currently senior official Alain Christnacht, who has served successive French presidents as an adviser on Pacific affairs).

The reference to “negligible risk” was removed from the law in February 2017, resulting in a steady increase in the number of successful claims. “For applicants living in French Polynesia,” reports CIVEN, “only eleven claims were accepted between 2010 and 2017, while 154 claims were favourably received between 1 January 2018 and 22 June 2020.”

Despite this advance, the law was changed again in December 2018 through an amendment proposed by Lana Tetuanui, who represents French Polynesia in the French Senate in Paris. Tetuanui is a member of Tapura Huiraatira, Edouard Fritch’s governing party. Her amendment sets an annual radiation dose of at least one millisievert, or mSv, as a measure for making a valid claim. While this is a low threshold, it once again requires applicants to prove their level of exposure — a difficult task when the French government still restricts release of radiation data under national security laws.

The Tetuanui amendment sparked renewed calls for reform of the Morin Law, with criticism led by Moruroa e Tatou (Moruroa and Us). This association unites thousands of Maohi workers, including labourers, truck drivers and scuba divers, who worked at the test sites on Moruroa and Fangataufa atolls and the support base on Hao atoll throughout the testing era.

Following the March 2019 death from cancer of Moruroa e Tatou’s long-time leader Roland Oldham, the association’s new president is Hiro Tefaarere. The former police inspector, trade union leader and politician has long been a critic of French colonialism. Speaking from his home on the island of Huahine in the Leeward Islands, Tefaarere echoes the call for action from politicians and church leaders in Tahiti. “The Tetuanui amendment is a serious problem,” he says. “We want this amendment to be withdrawn but we also want to go much further. It’s not just the Moruroa workers. According to official government figures, more than 20,000 people in French Polynesia died of cancer between 1996 and 2016.”

Tefaarere says he has met twice with CIVEN chair Alain Christnacht, “who I believe is a man of his word. We want him to speed up the compensation of all the victims of nuclear testing — whether they were military or civilian workers or people living on nearby islands who were contaminated.”

On 6 July, French president Emmanuel Macron reshuffled his cabinet, appointing Jean Castex as the new prime minister and Sébastien Lecornu as overseas minister. For Hiro Tefaarere, it’s important for France’s new leaders to engage with nuclear survivors in the South Pacific.

“It’s vital that President Macron, his new prime minister and the new government should meet with us, to discuss all of the concerns that we are raising,” he said. “We hope that President Macron will follow his predecessor François Hollande, not just to recognise the victims but to compensate them.”

Moetai Brotherson, who represents French Polynesia in the National Assembly in Paris, agrees that the compensation process has flaws.

“If the Tetuanui amendment had not been put into law, it wouldn’t be a problem at all,” he tells me from Tahiti. “Before, you only had to prove that you were in French Polynesia during a certain period of time, and you were eligible for compensation if your illness was on the list of diseases that are linked to nuclear testing. The ‘negligible risk’ provision was taken out of the legislation and things were moving smoothly. The number of files addressed was increasing.”

Brotherson was stunned last June when a joint committee of the French Senate and National Assembly reaffirmed that the Tetuanui amendment should remain in the Morin Law. “The most shocking thing about all of this was that the decision was taken without any of the Polynesian deputies or senators being present in Paris because of the Covid crisis,” he says. “So, there was none of us there to defend the fact that we didn’t want this millisievert level put back into the law. That was really a trick played behind our back, I would say.”

A 30 June statement from CIVEN released a complex twenty-page description of its methodology, which acknowledges the uncertainty created by the Tetuanui amendment:

The reversal of presumption is very different to that of “negligible risk”… [I]t is, however, the legal and regulatory norm which CIVEN must adopt. Aware that each case is different, CIVEN admits however that it is possible in certain circumstances to recognise as a victim those people who received a dose less than 1 mSv — especially because of the age of exposure for certain cancers or the location of the worker.

Brotherson calls on the new French government to deal with these inconsistencies in the way the Morin Law is operating. “The difficulty now is that the system will operate on a case-by-case basis,” he says. “We’ve seen lately a decision by the administrative court that supported the applicant, saying that CIVEN had to prove that the person had not been exposed to at least one millisievert of radiation. But decisions of this court can vary and so it’s now on a case-by-case basis.”

In Tahiti, Father Carlson of Association 193 agrees that inconsistencies in application of the law persist, despite recent reforms. He points to the case of two sisters from the Austral Islands, who met all the conditions set by the Morin Law. “One was given compensation, the other was refused,” he says. “We don’t understand why the second application was rejected when both women lived in the same environment. When we questioned CIVEN about this, they said that the commission was given the power to determine levels of exposure by the Tetuanui amendment.” In other words, he says, “the French state is both judge and accused.”

Father Carlson says he shares the pain felt by many victims, having been born in the Gambier Islands, an archipelago just 420 kilometres southeast of Moruroa atoll. “I am one of many witnesses to the generation that was sacrificed in the Gambier Islands,” he says. “Many people have died aged in their forties or fifties, sometimes suffering from multiple cancers at the same time. My two mothers — one biological, one adoptive — both died. What has happened to my family is not an isolated case, rather it is happening to thousands of Polynesians. That is what drives my commitment to this issue.”

President Macron was scheduled to visit Tahiti in April this year, to meet the government of French Polynesia and host a France–Oceania summit with Pacific island leaders. But his trip was postponed when the French government began grappling with the coronavirus pandemic. (France currently has 181,000 Covid-19 cases and has recorded nearly 31,000 deaths.) When the French president eventually arrives, he is likely to face public protests, as church and community leaders call for action on the legacy of twentieth-century nuclear testing.

Father Carlson says that Association 193 has three crucial demands for Macron: “Firstly, the removal of the Tetuanui amendment. Next, we would like to see the creation of an independent study into intergenerational illnesses. Thirdly, if President Macron is to visit Tahiti, we would like the French state to apologise for the many nuclear tests that transformed our island paradise into hell.” •

Reporting for this article was supported by a Sean Dorney Grant for Pacific Journalism through the Walkley Public Fund.

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Tess Ryan writes:

In the waiting room of a general practice a woman sits waiting to see the male clinician. She is uncomfortable and worries, because of past experiences, whether her concerns will be taken seriously or the doctor will see her problems as trivial.

An Aboriginal person also sits uneasily, knowing that the non-Indigenous people around her have no understanding of what her life entails, or what it means to be deemed a problematic statistic, or the assumptions that dictate how her health concerns are framed. If you have kidney or liver problems, it must be due to alcohol use. If you are a diabetic, it is due to the food you eat.

Also waiting is someone with a chronic condition. This person is running through her mind the list of concerns about her body, and the next complications she may face. When some new problem arises that can’t be explained neatly within diagnostic categories, she knows from past experience that she will be told, unsatisfyingly, “This is probably just a part of your condition.”

And an academic, who writes about race, cultural nuances and systemic failures across various institutions in the hope of disrupting them for the better, also waits for the doctor.

How many people sit in that waiting room? The answer is one. Me.

I walk into a medical practice with an understanding of health systems derived from my various identities: a Black Australian, a woman, someone with a deepening chronic illness, and an academic and writer with an understanding of the denial of Black voices and how health systems ignore the totality of people’s lives.

I come with many languages, some embedded in an emotional place that echoes through my body, and a history of being told I am less. I also bring an intellectual language for describing my understanding and experiences of racism and intergenerational trauma.

Observing myself in that waiting room, I am overcome with exhaustion. These discussions about race and racism that have come to the fore with the pandemic and with Black Lives Matter are necessary. But so utterly tiring. In case you haven’t noticed, we have been doing this work for a very long time.

____________

Melissa Sweet writes:

On a late spring’s evening in 2018 the Fred Hollows Foundation hosted a historic celebration in Adelaide. Guests whipped out their phones to record and tweet the beaming smile of the guest of honour, the president of the Australian Indigenous Doctors’ Association, Kris Rallah-Baker, with his arms wrapped around his parents. The celebration marked Dr Rallah-Baker’s graduation as Australia’s first Indigenous ophthalmologist.

Although he was just thirteen years old when the legendary eye surgeon Fred Hollows died in 1993, even then he had his sights set on becoming a doctor. But a careers counsellor at his school advised him against doing medicine, despite the fact that he was a top student, because “Aboriginal doctors were virtually unheard of.”

Low expectations are among the many ways that racism is expressed towards Aboriginal and Torres Strait Islander people, and Rallah-Baker experienced many other manifestations during his medical training. Not long before that graduation ceremony, he decided to put his concerns on the public record. “My own dealings with blatant racism, degradation, training delays, bullying, harassment and racial vilification are unfortunately considered an unremarkable experience amongst my Indigenous medical brethren,” he wrote in Insight, the industry magazine for the eye-care sector.

Initially the Royal Australian and New Zealand College of Ophthalmologists, or RANZCO, dismissed those concerns. But it quickly came under fire, with one headline referring to the college’s having engaged in “whitesplaining.” In an open letter, Aboriginal and Torres Strait Islander academics and health professionals, along with the Australian Indigenous Doctors’ Association and members of the Leaders in Indigenous Medical Education Network, condemned the college for “its callous disregard” of Rallah-Baker’s “experiences of racism and bullying and the attempt to publicly undermine his integrity and commitment to his profession and his people.”

Rallah-Baker had given RANZCO the chance to be part of the solution, they wrote. “We urge RANZCO to take up the call for the necessary institutional reform needed to ensure that Dr Rallah-Baker is not the first and last Indigenous ophthalmologist in this country. We urge you to listen and learn from his experiences and further, commit to action in the interests of Indigenous health justice.”

Within weeks the college issued a public apology — and Rallah-Baker is struck by how far the organisation has evolved since then. “I am absolutely impressed at how far they have come,” he tells me. “It’s been transformative for the organisation.”

He describes an increased focus on Indigenous eye health in training programs and an ambitious Reconciliation Action Plan. Aboriginal, Torres Strait Islander and Māori flags are now displayed prominently at college events, Acknowledgement of Country and other Indigenous protocols are in use, and the college has introduced cultural safety training — a strategy for tackling racism that encourages health practitioners to reflect critically on their knowledge, skills, attitudes and behaviour.

At a personal level, Rallah-Baker appreciates how RANZCO colleagues have rallied around at critical times, such as when the mining company Rio Tinto destroyed sacred sites at Juukan Gorge in Western Australia during Reconciliation Week, and when the Black Lives Matter movement brought global attention to the pervasive and violent effects of racism in all its forms.

But the point is not so much that a conservative, largely white organisation like RANZCO could change for the better. More significantly, this is just one of countless examples of how hard Aboriginal and Torres Islander people work, individually and collectively, to deal with racism — and not only in its most obvious forms.

The work has involved generations of scholarship, teaching, training, activism and advocacy. It has involved campaigning for policy and organisational change to tackle the institutional racism whereby society’s institutions and systems are designed to operate in ways that privilege some groups over others. In Australia, institutional racism is most glaringly evident in the failure of mainstream health, education, justice, media and other sectors to address the aspirations and needs of Aboriginal and Torres Strait Islander people.

Aboriginal and Torres Strait Islander people also contribute immense emotional labour in pushing for justice and change after loved ones have been harmed or killed. In her report on the death of Wiradjuri woman Naomi Williams from septicaemia at Tumut Hospital in 2016 — the result of an infection that is usually treatable — NSW deputy coroner Harriet Grahame acknowledged “the enormous pain Naomi’s family and friends feel and I thank them for their courageous attendance and dedicated participation in these difficult proceedings.”

Grahame saw their motivation as twofold: “They have been dedicated to trying to find out exactly why Naomi died, but they have also been looking for ways to improve health outcomes for other Indigenous patients in their local community. In this way they are honouring Naomi’s life and acknowledging her status as an emerging leader of her community.” Her report stresses the importance of Aboriginal people’s representation at all levels of the health system, and explores the impact of implicit bias and racism on healthcare for Indigenous patients.

Grahame documents “clear and ongoing inadequacies” in Ms Williams’s care, also finding that the care provided to her family after her death was “not compassionate or appropriate.” In the several months before she died, she presented at least eighteen times to the hospital with recurring, persistent symptoms, including vomiting and nausea, but felt her concerns were not being taken seriously because she was being stereotyped as a drug user rather than being referred to appropriate services.

The pandemic has brought the harmful impacts of racism to greater prominence, with headlines around the world reporting that Black people are not only more likely to contract Covid-19 but also more likely to die from it.

For Aboriginal and Torres Strait Islander people, however, such concerns are no revelation. Next year will mark the fiftieth anniversary of the Redfern Aboriginal Medical Service, the country’s first Aboriginal community-controlled health service. It was established to provide a culturally safe alternative to mainstream services, and since then it and other similar organisations have argued that tackling racism is critical to improving the health and wellbeing of Aboriginal and Torres Strait Islander people.

Yet these calls have fallen largely on deaf ears. In fact, the r-word doesn’t appear in three landmark documents in the history of Australian health reform: Australia: The Healthiest Country by 2020, the “roadmap for action” of the National Preventative Health Strategy (316 pages); A Healthier Future for All Australians, the final report of the National Health and Hospitals Reform Commission (279 pages); and Building a 21st Century Primary Health Care System, which spelt out “Australia’s First National Primary Health Care Strategy” (forty-four pages).

Last year saw the release of health minister Greg Hunt’s ambitiously titled but modestly scoped report, Australia’s Long Term National Health Plan to Build the World’s Best Health System (twenty-four pages), and plans for a new national preventive health strategy. Again, though, silence on this central issue.

Writing in the Medical Journal of Australia in March, University of Queensland health researchers Chelsea Bond and David Singh highlighted other omissions and pointed out that the National Health and Medical Research Council has yet to invest in a research program to understand and tackle racism in the health system.

By contrast, the National Aboriginal and Torres Strait Islander Health Plan 2013–2023, released by the government in 2013 and developed in partnership with Aboriginal and Torres Strait Islander organisations, made action against racism central, as did this year’s report from the Close the Gap campaign, which represents peak Indigenous and non-Indigenous health bodies, non-government organisations and human rights organisations. Yet the most recent of the federal government’s Closing the Gap reports mentions racism just once and contains no specific targets for tackling it, whether population-wide or in critical areas such as health, education or justice.

Among the Aboriginal and Torres Strait Islander organisations and leaders working overtime to break this silence is the Coalition of Peaks, which represents about fifty Indigenous organisations. In March, the coalition signed an historic agreement with the Council of Australian Governments setting out a power-sharing arrangement over the next decade, including a commitment to three-yearly Aboriginal and Torres Strait Islander–led reviews of Closing the Gap work.

The Coalition of Peaks is due to sign an agreement with federal, state and territory governments and the Australian Local Government Association on the next iteration of the Closing the Gap strategy. It is pushing not only for increased investment, according to its lead convenor, Pat Turner, but also for funding to go directly to Aboriginal and Torres Strait Islander–controlled organisations.

For Kris Rallah-Baker, the present moment — with the convergence of the pandemic and the Black Lives Matter movement — brings a unique opportunity.

The Aboriginal health sector’s response to the pandemic, faster and more effective than those from mainstream organisations, has been widely acknowledged. The role of the Aboriginal and Torres Strait Islander Advisory Group on Covid-19, which has been advising the Australian Health Protection Principal Committee, shows how tackling institutional racism through structural change can lead to better outcomes. The group, co-chaired by the National Aboriginal Community Controlled Health Organisation, or NACCHO, works on principles of shared decision-making, power sharing, two-way communication, self-determination, leadership and empowerment, according to a report in the Medical Journal of Australia.

Rallah-Baker, who is now president of the Australian Indigenous Doctors’ Association, or AIDA, says the Black Lives Matter movement has catapulted longstanding concerns into mainstream consciousness. “In Australia, we’ve had our own issues and debates around deaths in custody, and treaty, and reconciliation, right back to the Indigenous wars of independence,” he says. “By seeing those movements become mainstream in other Western countries, Australians start to question their own system.”

Weeks before our screens filled with the brutal images of a policeman’s knee on the late George Floyd’s neck, AIDA called out the racism Aboriginal and Torres Strait Islander people were experiencing in health services during the pandemic (for example, a patient who identified as an Aboriginal person was denied testing because priority treatment would only be offered to “real Aborigines”). AIDA also called for the early release of imprisoned First Nations people to prevent Black Covid-19 deaths in custody.

In April, the Australian Health Practitioner Regulation Agency backed AIDA’s concerns and encouraged Aboriginal and Torres Strait Islander people to lodge complaints if they had experienced racism or culturally unsafe care. “We will not tolerate racism particularly given the impact it has on community members accessing critical healthcare at this time,” said chief executive Martin Fletcher.

Just a few months later, non-Indigenous public health officials were warning Australians against attending Black Lives Matter marches, while remaining silent on public health threats such as police brutality and institutional racism. Indigenous health leaders spoke up strongly in response. The Centre of Best Practice in Aboriginal and Torres Strait Islander Suicide Prevention urged schools “to teach children about our history of racism, the social and historical determinants that underlie it, how this historical oppression continues, and what each of us can do to stand against racism.” NACCHO joined a broad coalition calling for the prime minister and opposition leader to support a bipartisan national anti-racism strategy.

Pat Anderson, chair of the Lowitja Institute, criticised the government’s lack of acknowledgement of the core concerns of Black Lives Matter. “We need to acknowledge that racism is deeply entrenched in Australia and is a public health emergency for Aboriginal and Torres Strait Islander people,” she said. But instead of taking urgent action on the Black Lives Matter concerns, “our government criticises us for our protests.”

In Melbourne, the chief executive officer of the Lowitja Institute, Narrunga Kaurna woman Janine Mohamed, a longstanding advocate for cultural safety, marched with her family and other colleagues working in Aboriginal health. As they walked, she later wrote, she thought about the linkages between punitive health and justice systems, and the stories of Ms Dhu, Naomi Williams, Tanya Day and David Dungay Junior and their preventable deaths. “So many of our people have been hurt and harmed by traumatising systems. Yet it took the death of an African-American man in the US to bring so many non-Indigenous Australians out on to the streets.”

At Wagga Wagga, in the NSW Riverina, Donna Murray, chief executive officer of Indigenous Allied Health Australia, joined hundreds of others in the Black Lives Matter march, where many wore masks and carried signs declaring “I can’t breathe.” She was moved by thoughts of the late Naomi Williams and her family, she tells me, and how little the mainstream health system had done to address the coroner’s findings. A descendant of the Wiradjuri nation of the Murrumbidgee River and of the Wonnarua nation of the Hunter Valley in New South Wales, Murray has spent decades working in Aboriginal and Torres Strait Islander affairs within government and community organisations.

What happens when all the non-Indigenous people go home? Indigenous Allied Health Australia’s Donna Murray. Honoring Nations/YouTube

On that day, she felt good to be on her Country and connecting with community after stressful months supporting members, many of whom were reporting increases in racism in their daily working and social lives as a result of the pandemic. “Fairly early on, it was quite obvious that it was going to be an issue to manage,” she says. Like other Aboriginal and Torres Strait Islander health workforce groups, her organisation ran webinars for members, stressing the importance of self-care and the cultural determinants of health as an antidote to racism.

Like Rallah-Baker, Murray believes that the increased global awareness arising from the pandemic and Black Lives Matter has created an opportunity to drive the anti-racism agenda. She would like a national process for tackling racism in health and education, including more support for Aboriginal and Torres Strait Islander people to make complaints about health services and health professionals.

She also wants non-Indigenous people and organisations to deal with racism. This is not the responsibility of Indigenous people and organisations, she says. “Our responsibility is to support our own people in caring for families and communities, and stay strong so we can keep identifying our priorities and find solutions through nation-building and self-determination.”

Murray suggests that I ask Speech Pathology Australia about why it came out in support of Black Lives Matter, one of a small number of mainstream health organisations to do so. When I question SPA national president Tim Kittel about this, he links the statement to other changes made by the organisation, including setting up an Aboriginal and Torres Strait Islander committee, making a formal apology to Aboriginal and Torres Strait Islander people for the profession’s history of causing harm, and encouraging members to undertake cultural safety training.

The SPA board is “firm” on the need to address the systemic discrimination and racism experienced by First Nations people, says Kittel. “There is so much more to do.”

At the end of the march in Wagga, Murray says she was left wondering: “When all those non-Indigenous people go home, what are they going to change and transform, so we don’t all have to keep coming back to march and speak out in another twelve months’ time, still in the same place, under the same dominant system? That’s always my question.”

Towards the end of a webinar hosted by the Australian Healthcare and Hospitals Association — coincidentally held the day after George Floyd was killed in Minneapolis — the AHHA’s strategic programs director, Chris Bourke, showed a complex “mud map” outlining multiple, overlapping ways that racism in healthcare is being dealt with through regulations and law.

It included the Australian Commission on Safety and Quality in Health Care’s implementation of new national healthcare standards released in 2017, race discrimination law, and the Australian Health Practitioner Regulation Agency’s work to embed cultural safety across healthcare.

Bourke, a Gamilaroi man, brings wide-ranging experience to this work, as Australia’s first Indigenous dentist and a member of the ACT Legislative Assembly from 2011 to 2016, where he held ministerial roles across portfolios including Aboriginal and Torres Strait Islander affairs, children and young people, disability, corrections, and education and training.

He says his father, an Aboriginal schoolteacher and principal, had a profound impact on his education. “I was incredibly lucky to be in such an environment and it protected myself and my siblings from many of the impacts of racism and discrimination that so many other Aboriginal and Torres Strait Islander people experience both in going to school and growing up.”

He studied dentistry because he liked science and doing things with his hands, and wanted to help people. He recalls working on Groote Eylandt in the Gulf of Carpentaria in the 1980s, when the dental clinic that served the non-Indigenous community was relatively well equipped but the one for local Aboriginal people “looked like something out of before the war.”

“There was no capability to do any fillings; you were there to take people’s teeth out. There wasn’t even an autoclave,” he recalls. “This was truly appalling ­— an example of a pattern of care, a model of care that’s been established as a result of institutional racism.”

Bourke says the concept of institutional racism recognises that organisations can serve some groups poorly because of the way they are run, managed, held accountable, resourced, located and staffed. It is about more than just staff behaviour, he says. Training and anti-racism courses will be ineffective if power structures don’t change.

Boards and management hold the key, but Bourke stresses the challenges involved. “It’s hard work. You have to play every note on the piano to get that change to happen.” But he is optimistic about “groundbreaking” developments in Queensland, where the state government, working with the Queensland Aboriginal and Islander Health Council and Indigenous academics, has drafted legislation to tackle institutional racism, including by requiring each hospital and health board to have at least one Aboriginal or Torres Strait Islander person as a member. With the pandemic constraining parliament’s operations, though, it’s not clear when the legislation will be debated, according to the office of Queensland health minister Steven Miles.

The South Australian health department is exploring a similar model, and is working with the AHHA on this. “That still leaves a number of other jurisdictions that could lean into this space and get some work done,” says Bourke.

In June last year, participants at the Lowitja Institute’s International Indigenous Health and Wellbeing Conference in Darwin outlined twelve priorities. “Colonialism and racism are determinants of ill health,” said one. “We call for comprehensive truth telling processes, and the acceptance of these truths, to dismantle colonial narratives and systemic racism in health research, policy and service delivery.”

While movements are growing for truth telling, as evidenced by the Uluru Statement from the Heart and, most recently, Victoria’s new truth and justice commission, the lived experience of many Aboriginal and Torres Strait Islander people shows a long road ahead.

__________

Tess Ryan writes:

Back in that waiting room I contemplate these developments, wearing all of my hats, including as president of the Australian Critical Race and Whiteness Studies Association.

My stomach churns reading again about Naomi Williams and her family. I think back to the time I spent with them, and the conversations we had about disconnections between cultural understandings of health and the health system. Recalling those days brings up all the anger and trauma, again. But this anger also fires us up to continue the fight.

We seem to be in a moment where change feels possible, and more commentary is recognising the many experiences of Black people and other people of colour. We are seeing very public denouncements of racism and an acknowledgement through numerous industries that those Black lives do matter. It is a powerful elixir to see allies also take on that work and young people in community wanting to carry the baton for changing these systems.

I want these developments to lead to systemic and structural change. It is the people within the system who need to see that change as necessary. At the micro or relationship level, I want to see behaviours shift in how we view various groups of people in connection with race. Rendering our bodies as statistical issues in health does nothing to change the paradigm of othering, and the focus on fixing the “condition” without having conversations about lived experience.

These developments are really only the beginning of the conversation we need to have. As an Aboriginal woman I will always want to work for that change, no matter how despondent I may feel. We look for the hope by looking backwards at all those who have advocated before us, and we look to the now and beyond in the strength of Black voices. We need to keep the momentum going, and for the policy changes to improve practice.

My hope is that I can walk into a medical clinic feeling like I am part of a team of people and professionals who will listen to my experiences, respect my different positions located in my identity, and work to build manageable solutions for better health and wellbeing. If I need a multidisciplinary team, then I expect them to work together with me and not sit in silos of their own discipline without connecting the dots to what can assist in better health.

I want to know that my mother is getting appropriate access to healthcare in her small town, that my brother doesn’t feel isolated from good health service delivery in a big city, and that a death like that of Naomi Williams won’t happen again. I want to see people like Kris Rallah-Baker supported and more Aboriginal and Torres Strait Islander people become ophthalmologists, or psychiatrists, or epidemiologists. We should see this as the norm and not the exception.

And I want other Australians to acknowledge and understand the hard work we do — as academics, professionals, policymakers, community members, commentators, digital media practitioners and artists — to try to educate you and open your eyes and ears and hearts. Our work, in navigating racism, informing people about discriminatory practice and working within institutional structures to create change, is immense.

We work to educate you in understanding difference, in pushing back against racial violence, in railing at the structures that think they can do better for us when we have our own solutions. Community-controlled health organisations have been doing exactly this during the pandemic, and these successes are regularly ignored.

Many Aboriginal and Torres Strait Islander people and communities have given decades of service to improve this country’s healthcare. It is time for other Australians to step up, take the responsibility and do the work, through your conversations and relationships as well as through changing policy and institutions and making yourselves accountable. We have been carrying you all this time without your even noticing. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

The post The long road to healthcare justice appeared first on Inside Story.

Australia’s first case of Spanish flu was detected in Melbourne in January 1919. Three months earlier, the states and the Commonwealth had agreed that, if the flu broke out, the states could impose border controls to try to limit its interstate spread. The affected state would notify the Commonwealth, which would then take complete control of all interstate traffic. Movement between the affected state and other states would be suspended for as long as the latter remained influenza-free; if they also had cases, then interstate travel could resume between infected states.

An exception was made for local movement across state lines by residents within ten miles of a border “in an area which is clean.” This meant that the residents of the twin towns of Albury and Wodonga, for instance, were permitted to cross the border.

Despite all the planning, the Victorian government took a fortnight to acknowledge that Australia’s first case of Spanish flu had been detected in Melbourne. By then, a soldier infected in the Victorian capital had travelled north across the state border. Within a day of New South Wales being proclaimed infected, Victoria finally informed the director of quarantine, John Cumpston, that it, too, had cases. Faced with Victoria’s tardiness, the NSW government considered the prior agreement to have been revoked and unilaterally shut the border.

Although Victoria carried on with business as usual, these events provoked a free-for-all among other states. Queensland prohibited interstate movement even for people living within ten miles of the border. South Australia blocked land traffic from Victoria, and Western Australia prohibited all land traffic from other states. Tasmania, meanwhile, required a week-long quarantine period, either before departure or on arrival.

Despite its own view that internal border closures were impractical and ineffective, the federal government was left powerless. This was seen as a real test of Commonwealth authority in the new federation, with an article in the Warwick Daily News arguing that “the actions of the State Governments in maintaining their own border quarantine restrictions was rapidly producing a crisis in the affairs of the Commonwealth.” The acting prime minister, W.A. Watt, negotiated a “system of cash and travel vouchers for citizens stranded outside their home states,” writes historian Humphrey McQueen, but beyond that, his powers of persuasion were “negligible.”

In practice, border closures were commonly evaded. People were smuggled across the NSW–Victoria border at points where supervision was lax, and the flu spread. New South Wales subsequently created a permit system at most border crossings and established quarantine detention camps at a couple of others, requiring people to stay for four days.

Not a single case of influenza was detected in the camps, though that seems to be a result more of poor testing than of an absence of disease, since numerous cases were discovered on ships arriving in Sydney and Brisbane during the same period. The director of quarantine scathingly described the camps as “either a useless infliction on persons travelling, or a positive danger, not only to the travellers, but to the community concerned.” While the ships were “entirely under control,” he wrote, “Inter-State quarantine has to face the difficulty of traffic at many hundred points along a border hundreds of miles long.”

Despite the innovations of the past century, it seems remarkable that we are still facing challenges at the borders. We now have drones and other surveillance technology, but the pandemic shows just how reliant we are on people themselves — to observe physical distancing protocols, to manage movement and, ultimately, to stop the spread of the virus.

Given how preoccupied successive governments have been with Australia’s external borders, it is also interesting to see a renewed focus on internal borders — which are, in fact, where the regulation of people movement began, centuries ago. The international controls on mobility with which we are so familiar — manifested in passports and visas — grew out of monitoring of movement within states, which was common across medieval Europe and continued into the modern period. Even Australia had its own “colonial passports” in the 1810–20s, issued to convicts, free settlers and visitors to establish their identities and facilitate movement within the colonies.

Up until Federation, the colonies had full discretion over who crossed their borders. But the High Court ruled in 1912 that section 92 of the Constitution (which provides for “free intercourse” among the states) and the act of federation itself limited states’ ability to deny entry to “undesirable immigrants” from other states. The court did recognise, however, that a state was entitled to take precautionary measures against dangerous people or other risks to “its health, or its morals.”

Subsequent cases have affirmed that while the Constitution guarantees freedom of movement across state borders, “a law may incidentally restrict movement interstate, provided the means adopted are neither inappropriate nor disproportionate.” It is now generally accepted that the Constitution’s “guarantee of internal mobility within Australia” may be subject to reasonable, legitimate restrictions which, in principle, include protecting the public from a pandemic. •

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For an event so predictable, the Victorian government seemed strangely unprepared. The optics were all wrong — armed police swarming to block off the towers amid stories of families left without food and unable to get other supplies. It’s strange that no response plan was waiting to be activated, providing a team of community liaison workers who could coordinate interpreters and the provision of food and welfare support, discreetly backed by police and emergency personnel.

Victoria has geared its Covid-19 response around a tightly controlled system of testing, case notification and contact tracing, poised to swoop on an outbreak and close it down. What this paradigm neglects is the fact that communities are complex webs in which information, resources and responses circulate in unpredictable ways. Covid-19 is not a single-event disaster, it is an unfolding pandemic during which adaptive and ground-up responses need to be nurtured and brought into the decision-making structure.

While the official discourse has been that SARS-CoV-2 can spread among rich and poor alike, some official statements have conveyed a sense that the poor have somehow brought this outbreak on themselves. Officials have admonished us not to use the opportunity for discrimination but have also made coded references to ethnic difference by attributing spread to large family gatherings.

It is hard to imagine a hard lockdown being pursued in the same way if outbreaks had occurred in expensive Toorak apartment blocks. Indeed, outbreaks may already have occurred there, but they would be taken as isolated occurrences rather than a dangerous cluster. Public housing blocks are already problematic social spaces, and have long been the targets of health and welfare “interventions.” These blocks have a prior label as potential hotspots, so almost any multiple of cases of Covid-19, no matter how small, would be enough to trigger drastic action.

This is not to say that such concerns are unwarranted. One of the emblematic sites of the 2003 SARS epidemic was Block E of the Amoy Gardens in Hong Kong. SARS spread through this private housing estate extremely rapidly, with more than 300 infections almost overnight and an eventual toll of 329 cases and forty-two deaths. After the event, there was meticulous inspection of possible routes of transmission, with plumbing systems and airshafts found to be the main culprits. Although recommendations were made for reviews of indoor air quality and ventilation design, there was little appetite for change, as usual, once the crisis had passed.

Criticism has naturally been directed at Victorian premier Daniel Andrews for failing to prevent the outbreak. Much of that criticism is misplaced, given that most of the dynamics of the outbreak are purely chance and similar outbreaks will inevitably occur across Australia. But the corollary of political leaders claiming credit for how well their jurisdiction has handled the epidemic is that they should anticipate opprobrium when things don’t go so well. Now might be a good time for politicians to adopt a more modest tone in the face of the epidemic.

A striking rebuke to the politicisation of epidemic dynamics came last week from Scotland. Its record in curbing Covid-19 — with per capita infection rates five times lower than England’s — has not stopped prime minister Boris Johnson from reacting furiously to suggestions that Scotland might restrict movement from the English side of the border. Scottish first minister Nicola Sturgeon gave an impassioned and justified defence of her government’s response to the pandemic, slamming Johnson’s resort to standard political sniping and declaring that if she were ever to refuse to consider life-saving options for political reasons, that would be the day she stopped doing her job properly.

Ever alert to the left’s discomfort with the deployment of uniformed services, there have been predictable calls from the Victorian opposition to add to the police presence by putting military forces “on the ground to assist with the growing Covid-19 crisis.” Putting aside the wedge-politicking behind this call, the advantage of the defence forces in circumstances like this lies in their training and the command structure under which they operate.

The most forceful criticism of the Andrews government is that its use of private contractors to provide security services in hotels for quarantined returnees may have been a mistake. Security work is among the areas of semi-precarious employment that have grown enormously over the past few decades. Along with cleaning, catering and myriad other service roles that are essential to modern enterprises, these services have been contracted out at the lowest bid. At the bottom of the pile in this business model are the staff themselves, who are rarely rewarded for loyalty and competence. Little wonder, then, that gaps in training and following protocols have appeared when these services are called on in pandemic response.

Covid-19 will continue to emerge across Australia. Public sector response teams need to be created to deal with this inevitability. They need to recruit staff, invest in training and provide reasonable job security. This will be expensive, but if the past week has proved anything, it is that it will be much less expensive than the alternative. •

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Six months into this pandemic and some patterns are becoming clear. For countries that have taken a strong containment-and-control approach and were able to catch the epidemic early — like Australia but also like China and South Korea — the daily count of new cases has come down from its initial peak, but relatively small upsurges have been occurring as new clusters of infection come to light. This pattern speaks to the virulence of SARS-CoV-2 — any amount of active virus, no matter how small, will break out at an exponential rate.

In a handful of countries, rates have been brought down to close to zero, and these are touted as places where elimination may be possible. New Zealand and Iceland are the prime examples, both having the advantage of being an island with a relatively small population. But even when numbers have reached zero, new cases have appeared, albeit attributed to arrivals from overseas.

The press briefings delivered by the World Health Organization on a near-daily basis since the end of January have been remarkable for their accuracy and consistency across a rapidly evolving pandemic. One of the very few cases where a correction was issued came after Maria Van Kerkhove, technical lead at these events, remarked on 8 June that transmission from asymptomatic individuals seemed rare. Her remark was seized on by the world’s media and interpreted as a reassuring signal that the majority of cases of Covid-19, which are asymptomatic, would not be able to transmit the virus onwards. The WHO quickly walked back that interpretation, making a distinction between those who are truly asymptomatic and will never go on to develop signs of illness, and those who are simply pre-symptomatic.

In fact, it seems that one of the keys to the virulent spread of SARS-CoV-2 is that its infectiousness is greatest a couple of days before symptoms appear. There is a relationship between viral load and both the likelihood of developing symptoms and the likelihood of transmitting the virus to others, but the extent of transmission from those with a low but not non-existent viral load is not entirely clear. The issue is important, because it goes to the question of elimination. If people who are asymptomatic and will never go on to develop illness can nevertheless transmit virus, even if rarely, then true elimination becomes massively difficult, short of testing the whole population on a regular basis.

In practical terms, there may be little difference between tight control and elimination strategies. The control strategies adopted by Australia and many East Asian countries depend on finding active cases and immediately implementing the isolation, quarantine and contact-tracing strategies needed to contain them. If this isn’t done, we now know that exponential spread will be inevitable.

In 2011 a previous pandemic, HIV, yielded a new term in the public health lexicon, “virtual elimination.” The example was the elimination of the transmission of HIV from mother to child: in the absence of any treatment, around a third of infants born to mothers living with HIV would become infected either prenatally, from blood contact during the birth itself, or postnatally through breast milk. But suppressing the mother’s viral load through effective antiretroviral therapy could bring this risk down to nearly zero.

In practice, of course, it was an enormous challenge to ensure that all mothers with HIV not only were diagnosed but were also given access to and used effective antiretroviral therapy. The global resolve to overcome these challenges meant that the goal of virtual elimination — defined as fewer than fifty transmissions per 100,000 births and a transmission rate of under 5 per cent — was seriously pursued.

Back in early April, the Grattan Institute was arguing that Australia should set itself the goal of total elimination of Covid-19. Only with total elimination, it said, could physical distancing be abandoned and full economic activity resumed. What we have learnt since then, not only from Australian experience but also particularly from China, suggests that virtual elimination may be more realistic. Precise criteria would need to be developed, and would include working towards zero levels of community transmission monitored by a mix of sentinel surveillance (random testing of slices of the population), location-specific quarantine when outbreaks appeared, and the mainstays of isolation and contact tracing.

The current Victorian upsurge has exposed some of the limitations of both state and national strategies. Any criticism seems churlish when Australia’s situation is compared with the constant news of the unmitigated disasters in the United States and Britain, but, even so, improvements can be made. In particular, the highly centralised Victorian response has given authorities there little flexibility to respond to changing conditions. Neither local hospitals nor local government are informed about the location of new cases as they are identified. Every positive case has a case management team assigned and cases are notified centrally, from where contact tracing is managed, but this leaves little capacity to develop a sense of local control of emerging cases. The lack of mutual commitment at the local level will make it much harder to introduce the local lockdowns that would seem to be necessary to manage outbreaks.

In the same way, public advice has been anodyne and not designed to foster active and ongoing commitment to control measures. In effect, the message from government, federal and state, has been “Trust us, we will find all cases and eliminate the threat. Go about your business normally.” This is the implicit message of the COVIDSafe app and the “snapback” slogans. A much more robust strategy would involve building mutuality into the response, with citizen action serving as a sign of social solidarity.

This is the real significance of the debate about mask wearing. Face masks undoubtedly contribute to slowing the spread of Covid-19, and the federal government’s reluctance to advocate, much less mandate, their use amounts to telling its citizens it has the problem under control, rather in the tradition of former Queensland premier Joh Bjelke-Petersen’s catchphrase, “Don’t you worry about that.”

Although its situation is very different from Australia’s, South Africa has been among the better responders to SARS-CoV-2. It has provided a very good example with its recent advice to citizens, developed by a collective of experts and based on the science of distancing, patterns of dispersion and amounts of exposure or dose needed for infection to occur. A range of practical tips are provided: as far as possible meet and conduct business outdoors, open windows, wear masks, keep one or two metres from others, avoid crowded spaces.

The key to harm-reduction measures is that they take the world as it is and reduce risk, rather than making impossible demands. The science is still unclear about how much transmission takes place from touching surfaces, for instance, or the extent to which the virus can float long distances in the air. But we do know that the risk attached to hugging and kissing is vastly higher than that of touching a banister, and spending a prolonged period in a closed room with someone else is orders of magnitude more likely to cause transmission than going to a physically distanced supermarket. And while touching your nose or face may provide a route of access for the virus, there is little point in telling people to avoid an almost constant unconscious action.

Quite rightly, Victorian health authorities have been reluctant to call the current spike a second wave of the epidemic. Waves are a way of describing long-term patterns involving thousands of cases — in many ways Australia has not even seen a first wave yet. But spikes, outbreaks and lockdowns are all terms with which we will need to become familiar. As Australia pursues the path to virtual elimination, and if we are not to succumb to an overwhelming fatigue, the most urgent priority is far more active citizen engagement than we have seen to date. •

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By the end of the season, according to an ANU survey, the majority of Australians had been directly or indirectly affected by the fires. Around 2.9 million adult Australians had property threatened or damaged, or were evacuated at least once. Around ten million people were affected by smoke, with many experiencing months of prolonged exposure. Another three-quarters of the adult population — around 15.4 million people — had indirect experience of the fires via family and friends.

If there was any good news, it was the fact that deaths and acute injuries were lower than in previous catastrophic fire seasons. Some thirty-four people died during the fires, compared with seventy-five deaths during the Ash Wednesday fires in early 1983 and 173 deaths on Black Saturday in early 2009.

Emergency physician Simon Judkins, immediate past president of the Australasian College of Emergency Medicine, has worked in many disaster settings. He sees the relatively low levels of injuries and deaths in the 2019–20 season as evidence that we have learnt from previous events. “We have got good at evacuating, triaging and getting people out of affected areas when necessary,” he says.

Many of the measures taken during the season were recommended by the Victorian royal commission set up after Black Saturday: clear and consistent public messaging and comprehensive evacuation plans, for example, coordinated emergency services responses and protocols for treating injured people on site or moving them to city hospitals.

Demand on hospitals and local health services was kept manageable by including GPs in field clinics and in the teams sent by the National Critical Care and Trauma Response Centre. Mistakes were made in communications and emergency services responses, of course, but improved evacuation and treatment meant that existing health services were not overwhelmed.

Still, health experts warn against complacency. As Judkins observes, the system functions well because of the dedication of overworked health professionals who do their best in an under-resourced system. He emphasises that an already stretched public hospital system can quickly become overwhelmed.

Iain Walker, director of the ANU Research School of Psychology, agrees. “If we have systems operating at capacity then there is no ability to deal with any additional problems,” he says.“For example, if the Covid-19 pandemic had reached Australia a month earlier when we had mass bushfire-related evacuations we would have had two conflicting events co-occurring and would not have coped.”

With challenges of this kind likely to become more frequent and more intense, Walker adds, “we need to build capacity into our health and social care systems and other essential services to deal with these situations.”

Simon Judkins also stresses the need to do more to support health professionals, first responders and volunteers who worked at the bushfire frontline. “How do we manage not only acute response, such as getting medical and nursing staff to the affected areas, but also ensuring that we support the health professionals on the ground who worked for fourteen-hour days for four or five weeks non-stop?” he asks. “Who looks after GPs working in those areas who absorbed a lot of stress and suffering in their communities? Who relieves solo practice GPs in places like Mallacoota when they need a break?”

The acute effects might be the most obvious legacy of the fires, but by far their greatest health impact came from the smoke they emitted. Because bushfire smoke can travel long distances and linger in the atmosphere, many more people were exposed than experienced the fires’ direct impact — and that makes our limited knowledge of its effects all the more worrying.

Clare Walter, a PhD candidate at the University of Queensland, has analysed the findings of nine Australian studies on the health impacts of air pollution. They show that, in the short-term at least, air pollution causes increased presentations to hospitals for chronic obstructive pulmonary disease, asthma, cardiac arrests and ischaemic heart disease.

These findings are supported by early research into the increased demand for healthcare during the 2019–20 bushfire season. Studies of air quality data for bushfire-affected regions of New South Wales, Queensland, the Australian Capital Territory and Victoria have found that the concentration of small airborne particles exceeded the ninety-fifth percentile of the historical daily mean on 125 of 133 days studied. In other words, concentrations were within the top 5 per cent on most smoke-affected days.

Researchers correlated this data with hospital admissions, emergency department attendances, GP consultations and ambulance call-outs to calculate that smoke was responsible for 417 excess deaths during the 2019–20 bushfire season and around 4500 presentations to hospital for cardiovascular and respiratory problems.

These findings suggest a strong relationship between bushfire smoke and specific health problems. But the exact causal relationship isn’t yet clear.

Almost all research on the health impacts of air pollution is based on measurements of airborne particulate matter, or PM, a mixture of solid particles and liquid droplets. PM is markedly elevated during fires and is widely monitored around Australia; that’s why researchers focus on its link with health problems.

The size and chemical composition of PM differs according to its source (apart from bushfires, the big ones are motor vehicles and coalfired power stations) and also from place to place. Evidence suggests that size matters, with small particles — those measuring less than 2.5 micrometers, or PM2.5 — being particularly damaging because they can penetrate deep into the respiratory system. But we know less about how their chemical composition affects humans.

Walters’s analysis has identified differences between the health effects of bushfire smoke and other forms of air pollution: specifically, respiratory impacts were comparatively stronger for bushfire pollution and cardiovascular impacts were weaker. But she stresses that only further investigation will show whether this is this is a causal relationship.

She has also found that bushfire smoke appears to affect adults more than children — the reverse of traffic pollution — although she can’t yet say whether this reflects biological or behavioural factors.

There’s another big unknown, too: the relative impact of heat and smoke exposure on health. With bushfires tending to occur on days of extreme heat, the two events can have a compound impact on humans. One recent Perth‐based study found a 6.6 per cent joint additive effect of PM2.5 and heat waves on admissions to hospital emergency departments. Again, the interaction is poorly understood.

Respiratory medicine specialist John Wilson, president of the Australasian College of Physicians, suggests that part of the reason that demand for healthcare rises during periods of smoke pollution might be that people with existing conditions are not sticking to their treatment plan. This may be because people delay regular medical appointments in response to public health advice to stay home on days of high pollution or because they are reluctant to seek help early for problems which then escalate into more serious issues.

On the question of the effectiveness of wearing a mask to reduce exposure to airborne particles, he is agnostic. “There is no clear answer from the research,” he tells me. “We have better information about their role in reducing infection due to the Covid-19 pandemic but there have been no clinical trials that definitively establish how effective they are.”

Wilson believes that Australia is the ideal setting for evaluating the effectiveness of masks, and stresses the need for their effectiveness to be confirmed before we face another major bushfire smoke episode. “When it comes to masks we have to either prove it or lose it,” he says.

More challenging from a research perspective is a better undersanding of the longer-term effects of bushfires. Existing Australian research in this area mostly comes from studies of the Ash Wednesday and Black Saturday fires, but the smaller scale of those fires means that it may not accurately predict the impact of the prolonged exposure last summer.

What is clear from the limited research is that the longer-term effects of smoke exposure go beyond the respiratory and cardiovascular systems. Some experts have suggested, for instance, that smoke exposure could increase the risk of Parkinson’s disease, Alzheimer’s disease and other neurological conditions. Some evidence also suggests that babies exposed to prolonged smoke in utero are at higher risk of low birthweight, which brings a heightened lifelong risk of conditions including cerebral palsy and visual or hearing impairment, and an elevated risk of heart disease in later life.

As some of these longer-term effects can be subtle and delayed, large-scale longitudinal studies will be needed to track groups over years and decades. The Menzies Centre for Health Policy’s Lesley Russell, an Inside Story contributor, is among the public health experts who have been arguing that more resources should be put into this kind of research.

She nominates four priority areas: longitudinal studies of all recognised firefighting personnel; longitudinal studies of communities most exposed to bushfires and bushfire smoke; greater awareness among and guidance for clinicians to help them recognise and deal with the health consequences of bushfires; and more focused research projects on high priority issues.

Some of the research gaps are being tackled with funding from the federal government’s Medical Research Future Fund, which has allocated $3 million for research into the physiological impacts of prolonged bushfire smoke exposure and $2 million for research into the mental health impacts of bushfires.

Although Russell welcomes this funding she is concerned by the lack of large-scale longitudinal studies. While she acknowledges this type of research can be very costly, she argues that “there are even greater costs involved in failing to undertake it — along with lost opportunities to improve the ability of the public health and healthcare systems to respond to future crisis situations.” She stresses the need for the findings of studies of the 2019–20 bushfires to be widely distributed and incorporated into the design of government services and programs.

ANU’s Iain Walker nominates social cohesion and resilience as other priorities for future research and action. He describes how the stress of a disaster can expose the “fracture lines” in individuals, families, communities and systems. Although social and community relationships are crucial to resilience, he says, they are often overlooked in research.

Given Australia’s vulnerability to natural disasters, Walker suggests that we should focus more on how to promote resilience to protect us in future disaster situations. He points out that understanding how resilience manifests in individuals, families, communities and systems will help in preparing not only for future bushfires but also for drought, pandemics, economic downturns and other crises.

Although the impact of bushfires on mental health often receives less attention, the evidence suggests that it can be more serious and long lasting. Research on the Black Saturday fires, for instance, found that mental health effects ($1 billion) exceeded the lifetime cost of deaths and injuries ($930 million).

But there are many gaps in our understanding of how natural disasters affect mental health. So far, the attention has been on short-term mental health needs of people directly affected by the fires.

After this summer’s fires, the federal government announced $76 million in funding for counselling and psychological services for people on the fire fronts, for bushfire trauma response coordinators, for emergency services workers and their families, and for youth mental health.

This funding expires in December 2021, though, and ANU’s Iain Walker warns that chronic and delayed mental health effects might not be visible for some time and could persist for years. He has been funded by the Medical Research Future Fund to examine these effects around Canberra and on the southern NSW coast.

“This is a neglected area of research,” he says. “There is some background research on how people respond to disasters more generally but still many gaps in our understanding of the specific impact of bushfires in an Australian context.” His research is looking at the range of psychological responses, including anxiety, depression and post‐traumatic stress disorder, and at the indirect mental health effects of the loss of possessions and property, damage to the environment and the sense of belonging to physical environment and associated changes in jobs.

The Australian Academy of Health and Medical Sciences agrees that mental health effects can emerge at any time and last for years. In its submission to the current royal commission it cites studies of the effects of the Black Saturday fires in 2009, which showed that one in five individuals in affected regions still had some form of psychological disorder five years later. The academy also found an increase in domestic violence in highly bushfire-affected communities. It warns that the twin stresses of Covid‐19 and the bushfires could exacerbate mental health problems.

Iain Walker highlights the vulnerability of healthcare workers, including first responders, who are not only affected by the bushfires themselves but also responsible for caring for others. “If a doctor or mental health worker is unable to work because of the impact of the crisis on themselves and their family then the whole system will fall over,” he says.

Specific population groups and communities were experienced more severe smoke-induced symptoms during last summer’s bushfires. They included people with pre-existing health conditions, elderly people, pregnant women, children, and people preparing to undergo surgery or anaesthesia.

We need to know more about the relative effectiveness of a range of strategies by making sure masks are used if and when appropriate, for example, by reducing the heat load in houses and public spaces, and checking indoor air purifiers and filters more frequently.

Respiratory specialist John Wilson’s message to government and health authorities is to pay more attention to pollution warnings and invest in targeted information campaigns informing people at risk about to reduce exposure and the importance of continuing to take medication, access routine treatment and seek early help.

Wilson also highlights the role that telehealth can play. “We have developed telehealth capacity as a result of Covid-19,” he says, “and we should continue to use this to protect vulnerable patients from infection and air pollution and reduce impact on emergency departments.”

People on low incomes are disproportionately affected by air pollution, says Clare Walter, not least because of their housing. “Australian houses are often not well insulated,” she says, “and even those with air conditioning often pull in air from outside if they don’t have a filter. People living in rented properties often can do little to improve the insulation of their houses and this can compound the existing risks associated with their higher rates of chronic disease.”

Walter recommends creating community-based “clean air shelters” to provide a safe environment for people during periods of high pollution. She also stresses the importance of ensuring clean air in childcare centres, residential aged care and other spaces occupied by vulnerable people.

Aboriginal and Torres Strait Islander people — with their higher rates of chronic disease and, in many cases, closer proximity to bushfire-prone areas — are also disproportionately affected by particulates and the loss of cultural resources during bushfires and other natural disasters.

But Indigenous communities can also be a source of knowledge and strength in combatting the adverse effects of bushfires. Their cultural and historical knowledge of land management and bushfire prevention practices can play a central role in bushfire prevention strategies, and non-Indigenous Australians can learn how cultural knowledge, values and practices assist Aboriginal and Torres Strait Islander peoples in dealing with environmental adversity.

And, of course, people living outside cities are often at the frontline of bushfire-related harms. These communities have received short-term assistance to deal with the immediate impact of the fires, but there are concerns that attention has now moved to Covid-19. “Workforce planning needs to take place to ensure that not only are health professionals brought into affected communities, but that they stay there for enough time to properly respond to the health issues caused by the bushfires,” says the National Rural Health Alliance in its submission to the bushfires royal commission.

Perhaps the group most exposed to risk are prisoners in jails near fire-prone areas. The NSW government was criticised for not moving prisoners in the Lithgow Correctional Centre, 140 kilometres northwest of Sydney, when a nearby bushfire caused surrounding houses and building to be evacuated. Around a quarter of the inmates in the prison identify as Aboriginal and Torres Strait Islanders, many of whom would have been more vulnerable to the effects of smoke because of their poorer health status.

The arrival of Covid-19 at the tail end of the bushfire season is a stark reminder of the many ways in which climate change can threaten health and well-being. It highlights the need for a comprehensive and nationally coordinated approach to dealing with the health impacts of global warming.

As Australia prepares for another bushfire season, which could start as soon as late August, we have a chance to use the lessons of summer 2019–to reduce the risk of harm from bushfires and other extreme weather events. •

The publication of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

The post Summer’s legacy appeared first on Inside Story.

Just like the pump handle John Snow removed to stop London’s 1854 cholera epidemic, there is something appealingly specific about this discovery. Will that chopping board be the harbinger of a second wave of Covid-19 in China? Is geopolitics implicated in the reference to salmon from Australia and Canada, two members of the “five-eyes” intelligence network being urged by security hawks to morph into an anti-China trading platform? What will be the temperature of the looming war: chilled or frozen?

Official accounts from China have poured cold water on the salmon theory, although some reports suggest that genomic analysis has found the newly identified strain of the virus to be from Europe. Nor should this outbreak be called a second wave — at least not yet. China celebrated its first day with zero locally acquired cases back on 19 March, and for the past three months new local cases have bumped along pretty much at zero or in the low single digits, so this outbreak is certainly larger. But that doesn’t mean it will necessarily spiral out of control, especially with Beijing’s swift deployment of mass testing and localised lockdown.

As in China, Australia’s epidemic is well controlled, and this is the reality we can expect for the foreseeable future — very few cases, mostly among travellers, and the occasional community outbreak, especially as workplaces become busy again. Everywhere, meat processing plants have proven to be especially prone to outbreaks, for reasons that aren’t well understood but may include the difficulty of social distancing and disinfection compounded by the industry’s notoriously poor labour practices.

It’s all part of what Tomas Pueyo calls “the hammer and the dance” — the largely successful outbreak-and-response strategy of countries containing the epidemic. Pueyo’s ability to coin a good phrase has helped him become perhaps the most prominent “lay” commentator to have emerged thus far in the pandemic.

There is no doubting that second waves of Covid-19 are inevitable. The only issue will be their size and the degree of resistance to reimposed bans on public gatherings and closures of schools and workplaces. For Australia and other southern hemisphere countries, the onset of winter and the normal seasonal surge in flu means the coming three months will be the most critical phase of the epidemic thus far. Little wonder then that the promise of a vaccine is so tantalising an escape route.

The World Health Organization’s list of vaccines under development now includes ten in clinical development and a further 126 at the pre-clinical stage. The race is being conducted in markedly different ways. In the United States, Operation Warp Speed retains its nationalist flavour, refusing to contemplate Chinese vaccine candidates. US authorities have settled on a small handful of prospects, including the much-hyped messenger RNA candidate from Moderna, which announced on 11 June that it had finalised preparations to move to phase III testing on humans.

Although the University of Queensland’s vaccine candidate was apparently on Warp Speed’s shortlist of eighteen candidates, it appears not to have made the final cut, but it is receiving support from the global CEPI alliance of public, private and non-profit organisations. Meanwhile, promising safety and efficacy results for China’s candidate have propelled it into phase III trials, but new cases have become so scarce in that country that trials have been moved to Brazil.

It is widely held that some sort of managed competition will be the quickest route to an effective vaccine, but already a proliferation of global alliances are offering to shepherd the process. Gavi, the global non-profit vaccines alliance, held its quinquennial replenishment meeting on 4 June, hosted by British prime minister Boris Johnson. US$8.8 billion was raised, including a billion dollars from the United States — there was a supportive message from Donald Trump — and Australia upped its contribution to $300 million.

Gavi has been a leading proponent of “advance commitments” to overcome market failure in vaccine development, locking in purchases ahead of development to reduce the risk to vaccine producers. It has launched such a scheme for a Covid-19 vaccine, reckoning that a US$2 billion fund would be enough to “enable twenty million healthcare workers to be vaccinated, create a stockpile necessary to deal with emergency outbreaks, and start establishing production capacity to vaccinate additional high-priority groups.”

Meanwhile, the pharmaceutical industry and public universities provide two contrasting models of how to get to a vaccine. Imperial College has launched VacEquity, a social enterprise to oversee the manufacture of its vaccine (if successful) as a globally available public good. “Right now we think the focus should be on how to solve the problem rather than how to make money out of it,” says Simon Hepworth, the college’s director of enterprise. Pharmaceutical giant Pfizer has partnered with BioNTech to combine its own experience in navigating the regulatory and production pathways with BioNTech’s messenger RNA candidate, even refusing government funding support on the grounds it would complicate and therefore slow its single-minded pursuit of an effective vaccine.

The danger is that the current Covid-19 vaccine landscape is sharing too few eggs around too many baskets. An interesting way of making sense of it all comes from the Washington-based think tank, the Center for Global Development, which suggests it is best to look at the research effort as something like an investment portfolio that deliberately tries to cover all bases — not only the type of vaccine developed but also how its manufacture can be scaled up and how it will eventually be used in different populations.

Vaccine anticipation is not without its drawbacks. On the model of flu vaccination, even were a vaccine to prove successful it won’t necessarily provide complete protection for every person. Given the pattern of SARS-CoV-2 spread, estimates suggest that a vaccine would need to be 70 per cent effective to be able to replace social distancing.

Perhaps more importantly, though, waiting for a vaccine might be like waiting for Godot. We can distract ourselves along the way — planning the push and pull mechanisms to be used if the much-desired breakthrough occurs, for example — but our hopes of a vaccine will risk diverting us from other ways of dealing with the acute pandemic crisis. I can’t help but be reminded of the AIDS experience: for decades, the refrain was “only a vaccine will really bring the epidemic under control.” That vaccine still hasn’t arrived, but in the meantime some countries committed to minimising new HIV infections and AIDS deaths with the full range of the social and medical innovations to hand, and those that didn’t continue to pay the price. •

Funding for this article from the Copyright Agency’s Cultural Fund is gratefully acknowledged.

The post Second-wave days appeared first on Inside Story.

But supporting the pharmacy profession need not mean supporting the business interests of retail pharmacy owners, especially given a string of reports and inquiries calling for changes to the five-yearly Community Pharmacy Agreements, or CPAs, that spell out how the government supports and regulates the industry.

The latest and most thorough of those reviews was commissioned by Mr Hunt’s predecessor, Sussan Ley, and came up with a detailed blueprint for change. Yet Mr Hunt is on the brink of signing another CPA with the Pharmacy Guild of Australia, which represents pharmacy owners, without having signalled any basic change in approach. Unless he significantly revises the terms of the CPA he will be committing the government to another five years of restricted competition and stifled innovation after the current agreement expires on 30 June.

The CPAs come with a big price tag for the federal government. The six since 1990 have committed the government to spending a sizeable chunk of its total health budget — in the case of the current agreement, $18.9 billion over five years — on pharmacy. This funding comprises $15.5 billion from the Commonwealth and $3.4 billion from patient contributions for the supply of PBS medicines and related programs, such as home medicine reviews.

Pharmacy services are vital, of course, but these agreements cover much more than the dispensing of medication. What started in 1990 as an agreement for funding prescription medicines has steadily broadened to include other regulatory matters, including the ownership and location of pharmacies. Controversially, the agreements restrict pharmacy ownership to qualified pharmacists (with a limit of five pharmacies per pharmacist) and prevent new pharmacies from opening within a certain distance of an existing pharmacy (usually 1.5 kilometres in cities and ten kilometres in regional areas). They also prohibit pharmacies from operating within or being directly accessible from supermarkets.

These are the rules that stop consumers from picking up prescriptions at their local supermarket or getting their scripts filled at their GP’s surgery by an in-house pharmacist. In areas that pharmacists don’t see as economically viable — including many parts of rural and remote Australia — the rules preclude existing healthcare services from running a pharmacy with a pharmacist in charge. For remote communities like Lajamanu in the Northern Territory or Purnululu in Western Australia, where just three pharmacies cover an area around the size of New South Wales, the nearest pharmacy can be eight hours or more away.

Given that these are among the most restrictive rules in any industry in Australia, it’s not surprising that a series of inquiries and reviews have called for them to be loosened. In 2014, for instance, the National Commission of Audit argued for “opening up the pharmacy sector to competition, including through the deregulation of ownership and location rules.” The following year, the Competition Policy Review declared community pharmacy to be one of the priority areas for “immediate reform action.” In 2018, a Senate committee recommended that the government “enhance competition in the delivery of pharmaceuticals listed on the Pharmaceutical Benefits Scheme, with priority given to consumers rather than pharmacy owners.”

Consumer groups and other health organisations have also called for change. The Consumers Health Forum of Australia argues that government support for community pharmacies should be “more transparent and contestable,” and the location rules should “be removed to allow for competition, innovation and new pharmacies.” The Grattan Institute recommends “cautious” removal of the ownership rules: “Like the location rules, these appear much more effective in protecting the commercial interests of pharmacy owners than in serving the public interest.”

The medical profession seems to agree. Harry Nespolon, president of the Royal Australian College of GPs, wrote last year that “the current laws are anti-competitive, without any benefits to consumers.” His words were echoed not long after by Australian Medical Association president Tony Bartone. And earlier this year the Australian Healthcare and Hospitals Association declared that the restrictions “should be subject to an independent, rigorous and transparent public interest test.”

The Pharmacy Guild’s position is that ownership and location restrictions are necessary to ensure quality, safety and accessibility. But the official inquiries have agreed that location restrictions aren’t necessary to guarantee a reasonable distribution of pharmacies in most areas of Australia. And they have pointed out that restricting ownership of a pharmacy to a qualified pharmacist makes no sense when many pharmacy owners don’t themselves work in their pharmacies, instead employing other pharmacists to provide services.

Brands like Chemist Warehouse and Priceline, which operate under franchise (or similar) arrangements linking individual pharmacies under a single brand, also undermine the Guild’s argument against the involvement of other parties, such as supermarkets, in retail pharmacy.

Part of the challenge for governments is that retail pharmacies are a health service wrapped up in a small business. Governments clearly have an interest in funding the supply of PBS medicines, and this may require some support for retail pharmacy infrastructure. But it seems clear that this support shouldn’t extend further than is necessary to ensure a reliable and high-quality supply of medicines.

An important role of the CPA is to set a fair price for dispensing PBS medicines, and to do this governments need access to accurate information about the costs of providing this service. But separating the health-related activities of retail pharmacies from their sale of cosmetics, perfume and other products can be difficult. The Guild has resisted attempts to obtain independent financial data from the sector, leaving the government largely reliant on the information provided by the Guild. With Australians filling around 300 million prescriptions each year, even a small overestimate in the cost per prescription can mean a large outlay for government and a windfall for pharmacy owners.

The widely recognised flaws in the CPAs don’t end there. Adding to the policy black hole is the lack of any independent oversight: the agreements are struck in secret, and no impartial body has the job of making sure they’re honoured.

It’s true that an agreement consultative committee oversees payments to pharmacists, making sure they meet their community service obligations and checking that the rules governing location and electronic prescriptions are observed. But four of its members are nominated by the Pharmacy Guild and four by the health department, leaving consumer interests, doctors’ groups and other experts entirely out of the picture.

When the fifth CPA was evaluated back in 2015 by an external team — itself a first — its governance and administrative arrangements were found to be out of step with normal public sector principles of contestability, transparency and independence. Among interest groups, only the Guild believed that the consultative committee was as representative as required, the evaluation reported. “Many stakeholders” believed that, at a minimum, the committee should include representatives of state and territory governments, the Pharmaceutical Society of Australia and consumer organisations.

In the same year, an Australian National Audit Office report found that the fifth CPA’s evaluation framework made no provision for reviews of the agreement’s two major financial components: pharmacy remuneration and community service obligation payments to pharmaceutical wholesalers. Pharmacy remuneration, which accounts for around 90 per cent of funding under the fifth CPA, “has not been fully reviewed since 1989.”

The Audit Office report is scathing about the health department’s administration of the fifth CPA. “Shortcomings in Health’s performance reporting and fifth CPA evaluation framework mean that the department is not well positioned to assess whether the Commonwealth is receiving value for money from the agreement overall, or performance against its six principles and objectives.” As a result, “there is no ready basis for the Parliament or other stakeholders to determine the actual cost of pharmacy remuneration delivered under the fifth CPA.”

Despite this finding, reporting on expenditure under the sixth CPA is still inadequate, with the relevant page on the health department’s website not having been updated since December 2015.

The range of criticisms from different bodies might explain why the government hasn’t yet acted, if not for the fact that it already has the blueprint for reform written by the independent high-level panel appointed by Sussan Ley.

The panel was chaired by economist Stephen King, a commissioner with the Productivity Commission, and its other members were Jo Watson, an experienced consumer advocate, and Bill Scott, a pharmacist and pharmacy owner and former president of the Pharmacy Guild. It was Australia’s most comprehensive review of the pharmacy sector and possibly the most extensive review ever of any sector of the health system.

A series of meetings with peak health consumer, pharmacy and industry bodies led to a discussion paper that generated over 500 written submissions. A series of public forums in cities and regional areas culminated in a live national webcast. An interim report in June 2017 generated another 201 submissions, with the peak bodies also giving feedback. Six commissioned research reports fed into the process.

In its final report in September 2017, the panel proposed a twenty-year plan to create a “consumer-centred, integrated and sustainable community pharmacy sector which is adaptive to the inevitable changes in healthcare given Australia’s ageing population, rapid advances in technology and ongoing PBS [Pharmaceutical Benefits Scheme] reform.” Forty-one of its recommendations were a consensus view of all three panel members, with two versions of the remaining three recommendations provided, one version supported by Professor King and Ms Watson and the other by Mr Scott.

Central to the review’s recommendations is the removal of ownership and location restrictions. In line with the findings from previous inquiries, the review found that the current restrictions reduce competition and allow monopolies or virtual monopolies to exist in local areas, resulting in higher prices, less variety, lower-quality service (reduced opening hours, for instance) and increased travel costs. It also recommended an end to the ban on pharmacies being accessible from within a supermarket.

The review echoed concerns about a lack of transparency and accountability in the administration of CPAs, recommending that future agreements concentrate primarily on dispensing services and include other stakeholders, specifically the Consumers Health Forum of Australia and the Pharmaceutical Society, the professional body for pharmacists.

Other recommendations included the development of an easily accessible and searchable atlas of all community pharmacies in Australia and the possible creation of a twenty-four-hour hotline to provide pharmacist advice and medicines information to consumers. Restrictions on the Aboriginal Health Service’s owning and operating a pharmacy at its own premises would be lifted. Machine dispensing would be trialled in a small number of secure locations not currently served by a community pharmacy. Homeopathic products would not be sold.

And the government’s response? In May 2018 it announced its support for just four of the forty-four recommendations. A further four were “accepted in principle,” three were rejected outright, and the remaining thirty-four were simply noted.

None of the recommendations accepted by the government involve significant policy changes or are at all contentious. Recommendation 2.5, for example, suggests that medicine information should be made available to consumers, and recommendation 6.3 states that pharmacy programs funding under the CPA should be based on evidence and deliver good value. All of the recommendations covering more substantial and controversial reform issues — including the location and ownership restrictions and the scope of the CPA — were left in limbo.

Lobbying by the Pharmacy Guild is certainly one important reason for the government’s noncommittal reaction. The low-profile Guild, a significant donor to both Labor and the Coalition, is one of the most powerful and successful lobby groups in Canberra. (In 2018–19 it was the largest political donor from the health sector and the sixth-largest overall.)

Commentators from both sides of politics have raised concerns about the Guild’s political influence. Former Liberal adviser Terry Barnes describes it as “superbly resourced and staffed, supported by its highly disciplined membership of pharmacy proprietors, and [with] a fearsome reputation for mobilising voters to support its campaigns.” Former Labor adviser Lesley Russell says that “pharmacies have a unique ability to garner public support for their causes from loyal customers.” Former Australian Competition and Consumer Commission chair Graeme Samuel has described the Guild’s lobbying tactics as “political blackmail” and argued that “they’re the most powerful union in Australia.”

Greg Hunt took on the Guild when he tightened up the sale of codeine, a move that the Guild opposed. A recent study found that this decision halved the number of codeine poisonings in Australia. But the minister allegedly backed down from a plan to allow prescriptions to cover a longer period (on doctors’ advice) after lobbying by the Guild. Longer prescriptions would enable consumers to minimise the number of pharmacy visits (especially important for people in rural areas, older people and those with disabilities) but would affect pharmacies’ bottom line by reducing dispensing fees and customer visits.

It’s important to remember that the Guild only represents owner-pharmacists, which means younger pharmacists are excluded from any say, direct or indirect, in the CPAs. Not surprisingly, the ownership and location regulations benefit existing owners but disadvantage new entrants. In fact, Stephen King and his panel found that employee pharmacists often face poor remuneration and uncertain career paths because of the anti-competitive nature of the retail pharmacy market.

Greg Hunt has not publicly revealed his intentions for the seventh CPA, and negotiations have, as usual, been conducted behind closed doors. But the process has changed in two ways this time round. For the first time, the Pharmaceutical Society of Australia (the professional body for pharmacists) will join the Guild as a cosignatory; and the government has held two round tables with a broad range of stakeholders to discuss issues relevant to the seventh CPA.

Whether these changes are merely cosmetic or rather will result in an agreement that better serves the health needs of the community remains to be seen. Given that the recommendations made by King and his panel generated wide support — even from some inside the pharmacy industry — Mr Hunt should have the confidence to act in the interests of the community rather than the Guild without significant political damage, and indeed with wide support in the health sector and the broader community.

Reform would also help provide a more secure future for the profession by opening up opportunities for younger pharmacists. It would create a more responsive environment in which the profession can evolve and change to meet the needs of the community, for example by expanding the role of pharmacists in providing immunisations, screening services and other healthcare directly to consumers.

Undoing three decades of policies and regulations is never easy, but the Covid-19 pandemic has demonstrated how major changes within the health system are possible and can even happen quite quickly.

Greg Hunt’s response to the King review also has broader implications. If he ignores the overwhelming evidence on the need for reform of the pharmacy sector, he will undermine the government’s credibility in other health policy areas. He will also reduce the motivation for stakeholder groups to commit the substantial resources required to participate in future inquiries and weaken these potentially powerful tools for policymaking. •

The researching and writing of this article was supported by a grant from the Judith Neilson Institute for Journalism and Ideas.

The post Wrong medicine appeared first on Inside Story.

A superior public health infrastructure with a large number of intensive care beds helps explain Germany’s comparatively low mortality rate. At no stage have hospitals been overwhelmed by patients requiring ventilators; in fact, German hospitals have been able to treat patients from Italy, France and the Netherlands. Crucial in keeping the number of infections manageable has been a nationwide lockdown and social distancing rules that have been observed by most people.

Over the past couple of weeks, Germany’s state governments have loosened restrictions. Most shops are back in business, many students have been able to return to school, and museums and art galleries have reopened. In one state, even restaurants are operating, albeit only for local residents.

Chancellor Angela Merkel and the sixteen state premiers met by video last Wednesday to discuss a further easing of the restrictions. Many of the premiers have been pushing for a speedy relaxation of the rules, and Merkel, the ever-cautious trained natural scientist, could do little but acquiesce. The only concession she secured was a commitment to reimpose restrictions locally if the number of new infections topped fifty per 100,000 inhabitants in a particular district. Since Wednesday, this Obergrenze, or upper limit, has been breached in five districts, but the local authorities’ response has been far less consistent than had presumably been envisaged by Merkel and the virologists advising her.

Many commentators have suggested that the rationale for easing restrictions quickly has been the realisation that Germany is reaching a tipping point. Germans overwhelmingly welcomed the lockdown when it was introduced in March, but now many of them are sick and tired of it and demanding a return to life as usual. A sizeable minority want to work, shop and go on holidays exactly as they used to. They are also no longer in favour of wearing the mandatory face masks on public transport and in shops, or of obeying social distancing rules.

The last time an Obergrenze became politically contentious was in late 2015 when the then premier of Bavaria, Horst Seehofer, demanded that Germany impose an upper limit on the number of asylum seekers admitted in a given year. This declaration embroiled Seehofer and Merkel in a bitter conflict lasting more than two years, which he eventually won. Now it is Merkel who insists on an upper limit, and again it is doubtful she will prevail.

Talk of an Obergrenze isn’t the only reminder of the so-called refugee crisis. Then, too, many politicians and journalists warned that “die Stimmung kippt” — that Germany was reaching, or had already reached, a tipping point, after which a majority of Germans would reject the refugee policies of the Merkel government. Then and now, those predicting a soon-to-be-reached tipping point could point to opinion polls. In September 2015, a clear majority supported the Merkel government’s decision to admit asylum seekers whose claims should have been processed in Greece or Hungary. Six months later, that was no longer the case. Now, polls suggest that support for the restrictions imposed by federal, state and local governments is declining fast.

Public protests are the most visible evidence of a change of public mood. Since the beginning of the lockdown, local governments have prohibited large public gatherings. But in a country in which rallies have long been an important means of protest, it has proven difficult for the authorities to ban demonstrations altogether.

Take 1 May, a day that’s more than any other associated with noisy rallies. This year the trade unions cancelled their traditional Labour Day marches, but that didn’t stop others. In Hamburg, for example, the authorities issued permits for forty-three public protests, always with the proviso that organisers agreed to an Obergrenze (usually twenty-five demonstrators), a stationary format, everybody wearing masks and a 1.5 metre gap between demonstrators. In almost all cases, protesters obeyed these rules.

Elsewhere, wild protests have taken place without the prior approval of local authorities, along with rallies whose participants haven’t adhered to stipulated conditions. Nearly all of these protests were directed at the lockdown. They have continued even after many of the restrictions were removed.

The first of these protests was in Berlin on 28 March. Protesters gathered on Rosa Luxemburg Square and one of the organisers, the writer Anselm Lenz, handed out copies of the Grundgesetz, Germany’s constitution. In an interview he said that the state had formed an alliance with the pharmaceutical industry and digital technology companies to abolish democracy. Only forty people attended what was later dubbed the first Hygiene-Demo, but the crowds were larger at subsequent rallies. Last Saturday, the police tried to restrict access to the square to ensure that the permitted number of demonstrators — a mere fifty — would not be exceeded, whereupon more than a thousand demonstrators gathered at nearby Alexanderplatz.

The largest demonstrations have been held in Stuttgart, the capital of Baden-Württemberg, in the affluent southwest of the country. There, the first rally took place on 18 April — but only after Germany’s high court had ruled that a ban imposed by the local authorities had to be rescinded. Last Saturday, about 5000 demonstrators gathered at Stuttgart’s Cannstatter Wasen, a large open space that is often used for festivals. Following the court ruling, the Baden-Württemberg authorities have been less restrictive and had granted a permit for a 10,000-strong demonstration.

Some of these demonstrations have been marred by violence. On two occasions, journalists were attacked. On others, there were squabbles between demonstrators and police who tried to enforce the stipulated Obergrenze and social distancing rules.

Similar demonstrations have been held elsewhere: from San Francisco to Melbourne, and from London to Naples. In all these cases, they have attracted a motley bunch of protesters, including, among others, conspiracy theorists, people belonging to far-right fringe groups, anti-vaxxers and civil rights activists. In some instances, populist leaders — most notably Donald Trump and Jair Bolsonaro — have given them their blessing.

What’s specific to Germany isn’t the much-reported gatherings in Berlin and Stuttgart but the numerous protests in small towns in East Germany. I believe these are the manifestations of the discontent that has made politicians nervous and eager to end the restrictions sooner rather than later.

In Zittau, a town of about 30,000 in the southeast of Saxony, close to the borders with the Czech Republic and Poland, a Facebook group of people critical of the lockdown formed about six weeks ago. On 6 April, the group sent an open letter to the local media. Its twenty-four signatories bemoaned “massive and disproportionate human rights violations.” They claimed that the restrictions represented the kind of totalitarianism that had last been seen thirty years ago. During the weekly rallies in Zittau, demonstrators have shouted, “Wir sind das Volk” (We are the people), the catchcry of the civil rights activists who took to the streets during the dying weeks of the German Democratic Republic in 1989.

Pirna is another medium-sized town in the southeast of Saxony. Like Zittau, Pirna is in an electorate where the candidate for the far-right Alternative für Deutschland (Alternative for Germany), or AfD, came first in the 2017 federal elections. There, the first wild protest was organised on 22 April by a police officer who represents the AfD in the local shire parliament.

Last Wednesday, about 250 people turned up for the latest demonstration opposite the town hall. Two days later, Pirna’s mayor, Klaus-Peter Hanke, invited three of the protesters and Saxony’s minister for social cohesion, the Social Democrat Petra Köpping, to join him in a panel discussion live-streamed on Facebook and YouTube.

Köpping did most of the talking, trying to explain the rationale behind her government’s response to the pandemic. At the conclusion of the event, one of the protesters said he much appreciated the fact that the minister had provided a lot of information. Earlier he had complained that the information supplied by the government was contradictory and sometimes incorrect, but also somewhat proudly admitted that for the past few weeks he had stopped paying attention to news related to the pandemic.

Outside of Saxony, Köpping is known as the author of the 2018 book Integriert doch erst mal uns! (You ought to integrate us first!), which argues that many East Germans had been the victims of German reunification, and that their experience, including their humiliation at the hands of West Germans, had never been properly acknowledged. During the panel discussion, she followed the script recommended in her book: she took the protesters’ concerns seriously and implied that they were legitimate, spoke patiently and conveyed empathy.

Only once did Köpping lose her calm. When one of the panellists complained that the police response to the demonstrations in Pirna had been heavy-handed, she said that it had to be seen in the context of a general deterioration of political culture. She talked about the personal abuse directed at her, and then made a reference to the protests against refugees in 2015, suggesting that they and the more recent protests against the lockdown were comparable.

There are indeed parallels between the opposition to government policy in 2015 and the opposition to government policy now. In both cases, the protests were sometimes initiated and at other times instrumentalised by the far right. As happened in 2015, protesters have objected to not being consulted and to being disadvantaged by government policies. Misinformation campaigns, some of them led by Russian state-owned media, fuelled some of the protests in 2015. In 2020, stories that the pandemic is less harmful than the common flu or is a ploy by Bill Gates can be traced back to Russian sources.

In 2015, those opposed to the government’s refugee policy saw themselves (rather than forcibly displaced non-Germans) as victims. In 2020, too, protesters perceive government policy as a means to harm them rather than protect others. (Of course, if the rate of infections were to increase substantially, everybody, and not just people in aged care facilities, would be at great risk of falling victim to the virus.)

Recent polls suggest that the Christian Democrats have benefited from the current crisis. With its support dropping below 10 per cent, the AfD’s efforts to capitalise on any disquiet about the government’s measures have failed. By and large, so have other attempts to connect an anti-migrant message to the concerns about the recent restrictions.

The government’s response to refugees in August and September 2015 is now widely seen as a mistake, and this assessment informs government policy in relation to the Covid-19 pandemic today. About a week ago, Matthias Iken, deputy editor-in-chief of the conservative Hamburger Abendblatt, wrote that the federal government was at risk of repeating its errors from 2015, namely failing to abandon a policy “that was initially called for but which could not be sustained. In the same way in which a country can’t accommodate close to a million refugees within a few months, it can’t be put on ice for weeks.” Favourable approval ratings, a sympathetic media and admiration from Germany’s neighbours would once again turn out to be but a “fleeting blessing.”

This historical analogy implies that Merkel’s policy in 2015 was politically suicidal rather than logistically impossible. After all, eventually Germany met the challenge of accommodating the refugees successfully. The analogy also neglects the fact that the narrative about the refugee policy’s political impossibility may be true for some parts of the country, including the southeast of Saxony (where vehement opposition to that policy began well before Merkel’s approval ratings nose-dived), but incorrect for others. The idea that Germany reached, and then went beyond, a tipping point in late 2015 has been shaped by a focus on what happened in places such as Pirna that were not representative then and are not representative now.

It would be a mistake to assume that local unrest in Pirna and Zittau will be replicated in the rest of the country. Hamburg may be just as unrepresentative as Pirna, but it’s worth noting that of the forty-three protests held in that city on 1 May not one was about the lockdown. While it’s reasonable to weigh up the costs and benefits of measures designed to slow down the spread of the coronavirus, it would make little sense to let government policy be informed by a misplaced fear of popular discontent.

This is not to downplay the significance of the current demonstrations. The protesters may well radicalise, as happened during 2014’s anti-immigration Pegida marches in Dresden and 2015’s anti-refugee protests. But the anger that drives the protests now, particularly in the east of the country, needs to be understood as more than simply a response to the lockdown, in the same way that the anti-immigration protests have never just been about migrants. For that reason alone, it would be wrong to make extensive concessions to the protesters — and in the process perhaps risk Germany’s exposure to the virus increasing exponentially — in the hope of ending the discontent. •

The post Tipping points appeared first on Inside Story.

In escaping an epidemic during his early childhood, Shakespeare was one of the lucky ones. Plague hit Stratford-upon-Avon just three months after his birth on 23 April 1564. In July, the vicar of the church in which he was baptised and in which his funeral would eventually be held had the mournful task of announcing the death of a weaving apprentice, upon whose burial entry is recorded hic incipit pestis — “here begins plague.” Over a period of six months the pestis cut a swathe through the population, but young Will was spared.

It is one of the many strange things about Shakespeare’s writing that, no matter what has happened since he lived, he seems to have anticipated it. An immediate and intriguing example came just a few weeks ago when the world welcomed a new book by respected scholar Jeffrey Wilson about tyrants in the plays. It was called (you guessed it) Shakespeare and Trump.

The corollary of pondering how his plays can illuminate our own changing times is to view the plays through current events, shedding new light on the playwright’s career and providing new readings of his works. Here are just three of many possible musings in our own age of pandemics, leaving aside his explicit references to cholera, malaria and other epidemics in the plays.

Shakespeare and plague

A pandemic could have destroyed Shakespeare’s career, but it turned into a blessing in disguise for him. When plague struck London in 1592–94, the government acted, as today, by banning mass audiences and closing down theatres. Shakespeare, as an up-and-coming dramatist and actor, was forced to make a rapid career change, and looked around for literary patronage as a non-dramatic poet. He published (crucially, under his own name) the long poems The Rape of Lucrece and the erotic Venus and Adonis. The latter was hugely popular, and would go through fourteen editions during his lifetime.

It was the first time the general public even knew of his existence, since playwrights were not individually celebrated and often wrote collaboratively. When the theatres reopened, Shakespeare’s name as the single, named author of a bestselling poem became a drawcard for theatre audiences.

He was also turning his hand to sonnets. From the appearance of Venus and Adonis onwards, many published quarto editions of the plays featured his name on the title page. His dedication to Venus and Adonis intriguingly describes the poem as “the first heir of my invention,” which seems further evidence that before this he was known only to a theatrical coterie, and that this book was intended to put his name into the public arena in a big way.

Terms used by contemporaries to praise his works — “sweet,” “mellifluous,” “honey-tongued,” “honey-flowing” — arguably apply more to the celebrated poem than to the plays. Contemporary writers linked his name with that prestigious verse publication; and Shakespeare and his theatre company never looked back. Who knows how many people today, their livelihoods destroyed in the short run, might be forced to change direction in equally lucrative ways?

Shakespeare and racism

I have always found Othello an uncomfortable play to teach and write about. But placing the play in modern terms (and depending on how it is produced), it can be seen not as underwriting racist attitudes but as critiquing them, showing how events can be exploited for a nationalistic agenda and become psychological pandemics in their own right.

Only one person in the play regards Othello’s skin colour as a stigma. Just as some world leaders today jostle to blame other nations and immigrants for the coronavirus, so does Iago view the Venetian Moor as an outsider who has the power to infect the population. Using disgusting imagery, Iago not only activates but creates white nationalists’ fear of others when he persuades even Brabantio, the father of Othello’s new wife, of how “unnatural” his daughter’s liaison is: “Even now, now, very now, an old black ram / Is topping your white ewe. Arise, arise,… / Or else the devil will make a grandsire of you.” He explicitly links race (“Barbary” were Saracen Moors or Turks) and bestiality: “you’ll have your daughter covered with a Barbary horse; you’ll have your nephews neigh to you.”

Brabantio has welcomed Othello into his house and accepted him as the natural leader of the Venetian military, but he falls for Iago’s blatantly racist populism, later treating Othello as a kind of epidemic in his own right: “That with some mixtures powerful o’er the blood, / Or with some dram conjured to this effect, / He wrought upon her.” In fact it is Iago’s virulent (virus-like) appeal to rhetoric of white supremacy that has infected Brabantio (but never Desdemona) and comes tragically to undermine Othello’s own sense of self.

The disturbing thing about the play is that some influential productions of Othello, even beyond apartheid South Africa and pre-bellum America, have generated a racially charged contagion that spreads even to the audience. But examples from current events show how Shakespeare, with unnerving, analytical accuracy, traced such prejudices back to a manipulative, evil individual’s ability to catalyse a social and political epidemic, no less dangerous for being psychological and political as well as physical.

Shakespeare’s death

We don’t know the cause of Shakespeare’s death in 1616, aged fifty-two, in his home at Stratford. Hypotheses have ranged from the prosaic (heart attack, stroke) to the colourful (syphilis, cocaine addiction, alcoholic poisoning, stress caused by family scandal). Surprisingly, though, contagion has rarely been considered, despite its frequency. Epidemics of various kinds, including bubonic plague, typhus, smallpox, yellow fever, chicken pox, malaria (known as ague) and others, were especially prevalent throughout Europe and England from 1606 to 1611 at least.

The catch-all word “influenza” to describe a “contagious distemper” was not used in English until the eighteenth century, but obviously this did not mean such conditions had not existed long before. They were not counted or clinically named or discriminated as they are today, and they certainly continued to circulate throughout the period, with the most common symptom being “fever.”

From 1616 onwards, whole native communities in New England were devastated by a mysterious epidemic, and although the English settlers declared this to be God’s punishment of their heathenish beliefs, the disease was almost certainly introduced by European sailors who may have been immune or asymptomatic because of exposure over generations.

In Shakespeare’s case, the fact that his will was drawn up and signed in a shaky hand less than a month before he died is sometimes taken as evidence of an ominous illness. The only near-contemporary account is that he died “of a fever” after an afternoon drinking with fellow dramatists Ben Jonson and Michael Drayton. Written fifty years after his death by a local vicar, the story may be apocryphal, but that phrase, “of a fever,” is all we have by way of evidence.

Typhus in particular broke out in 1616 England. “Fever,” sometimes induced by plague, seems to have attended the deaths of playwrights in London, including Robert Greene, John Fletcher and possibly Thomas Middleton. Nor did it spare Shakespeare’s own family, since his son Hamnet and three of his sisters also died of plague. If Shakespeare didn’t die of a common epidemic or pandemic, then he was statistically quite lucky to have escaped the scourge. •

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For me, the turning point came towards the end of February during a celebration for friends’ birthdays in a vineyard restaurant on a glorious late summer’s day. At the table was a young doctor on his way to specialising in intensive care. He confessed to being obsessed with Covid-19, unusual at the time when it was barely a talking point in Australia. A major metropolitan hospital was making contingency plans to turn over one wing to an isolation ward, he confided. He wondered how people would cope if dire health rationing became necessary.

Since then, we’ve seen an explosion of knowledge. Never before in human history has so much been learnt about a new disease in so short a time. But for all we now know, there is even more that, as yet, we don’t.

We know that since the first identified outbreak in Wuhan, China, around 3.5 million cases have been confirmed. We also know this is an underestimate, as many people are infected but never show symptoms. Until very recently the only people tested have been those with signs of respiratory illness, and in many places testing is hardly available.

We know that 250,000 deaths have been attributed to Covid-19 worldwide, but that this toll is also certainly an underestimate. Cause-of-death statistics are notoriously hard to collect consistently, especially with an emerging or stigmatised disease. Even where health systems have a good handle on hospital deaths, deaths in aged care facilities or at home may not be recorded accurately.

Despite the difficulties attached to attributing mortality and the lack of a precise denominator of the numbers infected with the virus, we do know that the death rate from Covid-19 is substantially worse than from seasonal flu. Australia’s case fatality rate seems to sit around 1.4 per cent, not dissimilar to the rate found in other places — like mainland China, South Korea and Taiwan — where testing has been extensive and the first wave relatively contained. The Diamond Princess has inadvertently provided a closed system to benchmark the fatality rate, with the ratio of deaths per infection coming in at 1.3 per cent, and double that if you count deaths per case of illness. Not surprisingly, a cruise ship population skews old, and Covid-19 has a steep age gradient, so corrections have to be made to estimate potential fatality rates across the whole population.

We know that infections start circulating well before they come to the attention of public health authorities, but nevertheless that physical distancing can strongly curtail epidemic spread. The repertoire of measures includes limiting the numbers of people gathering in close proximity, using face masks to limit the spread of droplets from coughing or sneezing, handwashing with soap to kill the virus on the hands, and disinfection of surfaces. But there is no magic formula or proven combination.

We know that SARS-CoV-2 causes respiratory distress with a complex mechanism of action. “Cytokine storm” is such a resonant metaphor it has become a major window into how the body’s immune system can produce a deadly over-reaction. And, at the molecular level, we are learning how spike proteins on the virus’s surface break into cells and enable its particles to replicate.

We know that the risks of becoming seriously ill with Covid-19 are related to other health conditions, especially diabetes and obesity — though not, surprisingly, to asthma or smoking.

We know that wealth and status are no barriers to infection, but that, once you’re infected, your chances of becoming sick or dying correlate closely to existing patterns of inequality. We also know that new diseases, as they always do, give a boost to long-rehearsed prejudices: the West blaming the East, the South the North, Hindus blaming Muslims, Chinese in China blaming Africans, Africans in Africa blaming Chinese.

And we know that for every example of selfless solidarity in the face of a crisis there will be a counter-example of ruthless advantage-seeking, whether by predatory drug companies, disease profiteers, wealthy sporting codes or governments continuing their geopolitical manoeuvring.

But what of the known unknowns?

The list is as long as your arm. Will a second wave of the epidemic be worse than the first? Will there be perpetual waves until 70 per cent of the world’s population is infected? When will effective treatments and a vaccine be developed? How long will people put up with physical distancing? Will global supply chains be broken forever? Will we have to choose sides in a war between the United States and China?

Science, with a capital S, is often presented as a done deal. Just like the sign advertising “antiques made daily,” though, even newly minted scientific facts come with a patina of received wisdom, at least until the next paradigm shift comes along.

What is fascinating about the current frenzy of Covid-19 research is that the lid is being lifted on the messy and conflicted process of science in action. Take two examples, epidemiology vis à vis children, and pharmaceutical treatments.

Federal education minister Dan Tehan picked a bad morning to rip into Victorian premier Daniel Andrews’s “lack of leadership” in not reopening schools for face-to-face learning. Within hours, Victoria’s health minister was announcing a school closure and three-day disinfection following the discovery of an ill teacher, and New South Wales was to follow with another. The scientific ground is also shifting under the Australian public health advice that children in schools pose little risk.

Virologist Christian Drosten has become an unlikely star in Germany’s Covid response. Like Greece’s epidemic spokesperson, Australian-born Sotiris Tsiodras, it seems today’s heroes are made of calm and frank communication combined with prodigious expert knowledge. Drosten, one of the world’s leading coronavirus experts, last week concluded after a close examination of nearly 4000 samples in Germany that “viral loads in the very young do not differ significantly from those of adults. Based on these results, we have to caution against an unlimited re-opening of schools and kindergartens in the present situation. Children may be as infectious as adults.” Similarly, an analysis of data from Shenzhen, China showed that “children are as likely as adults to become infected with SARS-CoV-2 after close contact with an infected person.”

Australia may need to abandon its current rationale for keeping schools open: the idea that children are unlikely to become infected or to be infectious. That doesn’t mean there may not be other reasons — like the needs of those children whose homes pose a danger to them, or the inability to provide childcare options to health and other essential workers. But the idea that schooling is developmentally essential, at least as provided under the current nineteenth-century industrial model, is not a strong rationale.

Why not take this opportunity to update schooling for today’s information-unlimited environment? The only basic skills that are essential are literacy, numeracy and discernment, or how to tell fakes from the genuine article. Once these are mastered, experiential learning can provide the rest. The economy no longer needs young people to be disciplined in sitting at a desk and obeying institutional authority, and the other main task of schooling — to filter access to social goods under a veneer of meritocracy — could also do with a major rethink. With Australian universities reeling under the sudden disappearance of overseas students, why not fill the vacant places with high school students, at liberty to choose a place that most suits their interests?

The science of drug development is also being laid bare. As yet, no effective treatments exist, with much-touted possibilities such as hydroxychloroquine having disappointed. The latest buzz is around Remdesivir — but experienced players know to tread carefully.

The first placebo-controlled study of Remdesivir showed no shortening of the period of illness. With more adverse events in the Remdesivir group than for those receiving placebo, the trial was stopped. This was the trial whose results were made public early by the World Health Organization, much to the annoyance of the drug’s manufacturer, Gilead. When the peer-reviewed publication of the trial appeared on 29 April, Gilead was much better positioned to seize control of the narrative. It issued a press release about its study comparing five and ten days’ use of Remdesivir, both with similar times to recovery.

Also on 29 April, results of a US National Institutes of Health study showed a modest but statistically significant improvement in recovery time — eleven days compared with fifteen days — for patients receiving Remdesivir compared with placebo. This was enough for Anthony Fauci (whose role as the country’s most senior virologist makes him a beacon of sense in Donald Trump’s media conferences) to liken the announcement to the first results for AZT in combating AIDS thirty-four years ago — a hopeful proof of concept that a drug had antiviral impact, but a long way to go before finding truly effective therapies.

Gilead is a master at shaping the environment to its financial advantage. This epidemic is no exception: in the first quarter of 2020, it upped its spending on congressional lobbying in the United States to record levels. In this case, the game is to establish Remdesivir as the “standard of care” against which other treatments will be judged. Even other drugs found to be a better candidate will find it harder to muscle their way in to the fiercely competitive environment where discovery, trialling, regulatory approval and manufacturing all pose significant hurdles.

Although international trade rules include provisions for public health needs to trump intellectual property rights, those provisions have proved inadequate against the industrial-pharmaceutical juggernaut. That is why Médecins Sans Frontières has assembled a large group of partners in a campaign for access, under the trenchant slogan “No Patents or Profiteering on Drugs, Tests, and Vaccines in Pandemic.” At best, its prospects for success also count as a known unknown.

What then of the realm of unknown unknowns?

This is the dangerous territory where conspiracy theories lurk, providing a rod of certainty amid the fog. Will a secret dossier be produced “proving” Covid-19’s origin as a weapon of mass destruction?

If Scott Morrison is sincere in arguing that an independent inquiry into the origins of SARS-CoV-2 is plain common sense and not a dog-whistle attack on China, then he ought to be taking the phylogenetic suggestion that when the virus first appeared closest to its likely bat progenitor, it was in Australia and the United States alongside China. “What if it was an Australian bat that first passed on this disease?” he needs to say. “Just like the hendra and lyssa viruses that first made their appearances in Australia. We’re fair dinkum, we’ll cop that.”

The only thing we can be sure we know about unknown unknowns is that there will be some. Meanwhile, for the next few years, get used to endemic Covid-19 — not eradicated, barely contained, and at least ten times worse than the flu. •

The post Knowns and unknowns appeared first on Inside Story.

Until that day in March we tended to see the virus as a Chinese problem or, even more specifically, a Wuhan problem. But by early that month it was clear that the virus was out of control in parts of Italy, where overstretched healthcare workers were imposing harsh and brutal triage on infected people. It was also clear that without strong action we would soon be in Italy’s situation, and that our healthcare system, too, was not equipped to cope with such a surge of cases.

So, on Friday 13 March, three days after we recorded our hundredth case, prime minister Scott Morrison announced that “non-essential gatherings” of 500 or more would be banned from the following Monday, though he would still be “going to the footy” that weekend.

As had been the case in most countries, policymakers still didn’t seem to understand — or chose not to understand — that although the numbers were small they were compounding rapidly. But two weeks after we recorded our hundredth case we recorded more than two thousand cases. Our infection rate was growing at 23 per cent a day, a pace that would have seen the whole country infected by early May.

That didn’t happen, and it was never going to happen. Regardless of government policy, people would have been taking their own precautions as awareness and fear levels rose. Under pressure from the states, the federal government introduced strong restrictions, the prime minister decided not to go to the football, and by the end of March we had started to turn around the rate of new infections.

The tension between the states and the federal government transcended traditional party lines, and was compounded by the fact that the states are responsible for hospital care but the federal government is responsible for any necessary fiscal stimulus and for making payments to support those who lose income in any lockdown.

By now, as we track towards something between the federal health minister’s aim of “effective eradication” and the prime minister’s “suppression” (in practice they may not be very different) the message from Canberra is that we should be thinking about how we emerge from the crisis and get back to business as usual.

In terms of health policy, business as usual would mean putting those temporary hospitals back into store (or, if we’re confident there won’t be a resurgence of cases, sending them to Indonesia) and allowing private hospitals to get back to providing a full range of elective surgery.

But even if Australia remains relatively unscathed by the virus, a return to business as usual is unlikely. We can’t escape the consequences of a worldwide recession, we will have to sustain tough border controls, and we have higher-than-expected public debt to deal with. Coping with these are all within the realm of general economic management: we have come out of economic crises before. More basically, though, the virus and governments’ responses have challenged many ideas about public policy.

Just as the speed at which the virus proliferated took many by surprise, so too did the speed of governments’ reactions. Economic narratives turned around in a few days: the federal government’s focus on a budget surplus gave way, first, to the need to stimulate the economy, and then to the need to support incomes, producing the most extraordinary fiscal and monetary boost the nation has ever seen. What we had assumed to be fixed ideological positions suddenly didn’t look so fixed.

As Peter Brent has pointed out, we shouldn’t be too surprised by these economic and fiscal U-turns: governments of all persuasions have responded to crises with large Keynesian stimuluses. Perhaps it’s just that for the first time since 1982 an economic shock has occurred on the Coalition’s watch.

But a far greater shift is occurring — or at least should be occurring, as Adam Triggs argues — and it seems to have taken people across the political spectrum by surprise. One important aspect relates to the responsibility of government for the health and safety of its citizens.

“Health” or “the economy”: the false trade-off

As the virus started to spread in Europe and here in Australia, policy choices were generally framed as a trade-off between protecting people from the illness and death, and maintaining the strength of the economy. This way of thinking is similar to the idea that dealing with climate change involves a trade-off between a government’s economic and environmental responsibilities.

It’s a way of thinking well entrenched in our models of public policy and manifest, for example, in the idea of “triple bottom line” reporting, as if “society,” “the economy” and “the environment” are separate entities competing for policymakers’ attention.

This categorisation makes no sense. “The economy” is not some entity apart from society. We work, buy, sell, lend, borrow — we engage in economic activity, that is — in order to satisfy human needs, and these activities are all social activities. But so many policymakers, journalists and academics, “left” and “right,” take that categorisation for granted.

As the economic philosopher Karl Polanyi pointed out, the market is, or should be, subservient to society, subject to society’s norms and moral codes, as it has been in most of human history. But when he wrote The Great Transformation in 1944 he foresaw that the market would assume primacy after the war. We would come to live in a “market,” not in a “society,” with society subordinated to its rules. That was to be the great transformation.

As this transformation developed, so did economic indicators such as gross domestic product come to assume importance, as did financial indicators such as the government fiscal balance, no matter how far removed they were from human welfare. So too did the idea of a “job” assume an importance in its own right, regardless of its value to society or its conditions. Mortgage brokers or nurses, marketing executives or teachers — it didn’t matter much. Considerations of labour productivity got pushed off stage in favour of gross employment numbers.

Unsurprisingly then, as the virus started to spread, policymakers’ prime concern was to find a way to handle the virus in a way that would do minimum damage to “the economy.”

In Britain, that priority was manifest in prime minister Boris Johnson’s early talk of letting the virus rip through the nation to achieve rapid herd immunity. This rested on the idea that the virus could be released in a controlled way, so as to achieve that immunity over a period long enough not to overload the health system. Even this idea lacks logic: there is no assurance that those who contract the virus gain enduring immunity, and if numbers were kept low enough to ensure the healthcare system could cope it would take around twenty years for a majority of the population to become infected.

The idea is not completely off the table, however. As Covid-19 hospitalisation rates fall in many countries there are calls to ease up on restrictions, even if that results in more infections, because the health system can handle the load. The unstated premise of this idea is that healthcare workers are like frontline soldiers who can be sacrificed in order to achieve the greater good of protecting “the economy.”

When people realised what the idea of prioritising “the economy” entailed, they rejected it. Only a few hard-right governments, such as the Bolsonaro government in Brazil, have failed to yield to people’s demand for safety to take priority. In the United State a foolhardy president and a handful of hardline Republicans have demonstrated to the world that “economy first” results not only in unnecessary death and suffering, but also in unnecessary economic pain.

Politicians are starting to understand that the public reaction is not about shifting the slider in a trade-off towards the “health” end and away from “the economy” end. Rather, people are rejecting the whole notion of a trade-off.

In Australia, shadow health minister Chris Bowen showed he understands this shift when an interviewer suggested that “health had trumped the economy.” His reply: “I don’t accept that health trumps the economy. It’s the same question. What is ultimately best for Australia’s health outcomes, is also ultimately best for Australia’s economic outcomes.”

This is not just a “left” or Labor perspective. Bowen was, in fact, echoing a point made by the International Monetary Fund in its April World Economic Outlook: “Necessary measures to reduce contagion and protect lives will take a short-term toll on economic activity but should also be seen as an important investment in long-term human and economic health.”

In more general terms Mikeark Carney, the recently retired governor of the Bank of England, wrote in the Economist that the economy must yield to human values. A seventy-five-year period in which the market price of everything has become the value of everything needs to be reversed. The discovery that citizens see their health and safety as overriding concerns should lead policymakers to rethink their basic models: we live in a society, not in a market.

The partial response: tweaking the healthcare system

The notion that we should put the market back in its proper place has been gathering strength for some time, but it is doubtful if most governments understand this. Rather, as they try to juggle competing fiscal priorities in a post–Covid-19 world, they will try to tweak budgets to cope with specific problems in healthcare revealed during the crisis. Until the old categorisations become manifestly untenable they will still see healthcare as a “social program” separate from “the economy.”

But, as Jennifer Doggett has pointed out, the pandemic has a number of strong lessons for healthcare in Australia.

Even if we are entirely lacking in compassion we can’t escape the reality that healthcare, for the most part, is a public good. There is nothing like a serious infectious disease to make you realise that you have an interest in my health and I have an interest in yours.

Equally, there is nothing like finding out that a private clinic may have been holding back vital information about Covid-19 infections to drive home the message that the profit motive can be to the detriment of patients’ interests. This is not about public or private ownership — it’s about incentives. A government-owned hospital can be subject to stronger, potentially damaging financial incentives than a privately owned clinic with a community service objective.

There is nothing like seeing infections break out in places where we crowd the powerless and the poor in squalid living conditions — foreign workers in Singapore, jail inmates throughout the world, seasonal horticultural labourers — to make us understand the social determinants of health.

And there is nothing like seeing a prime minister born to the upper class in a class-ridden society like Britain’s thank his country’s nationalised health service for saving his life to convince us that we have a shared interest in good healthcare. Here in Australia we didn’t have so stark a demonstration, but those who had put their faith in private health insurance suddenly realised that if matters became serious their insurance policies were worthless. As Herman Leonard of the Harvard Business School says, “The hard jobs are left to the public sector.”

Will these lessons endure and help reshape our healthcare arrangements, or will we be caught off guard once again when the next pandemic hits? We are more likely to learn from this experience if we realise that all public policy is social policy. •

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Under border restriction regulations imposed in Queensland since early February, Sladen was summoned to appear in court, where, on 6 May 1919, he was sentenced to a month’s imprisonment. Across two borders to the south, the Victorian branch of the Australian Natives Association protested against this treatment of a returned soldier; Sladen nevertheless served out his time at Brisbane’s Boggo Road Gaol.

Sladen’s service to his country hadn’t counted for much for the sentencing magistrate, who believed the higher duty of deterring others weighed heavily at a time when the “public health was so gravely concerned.” In fact, Magistrate Dean would have a busy month dealing with cases involving breaches of quarantine, handing out his severest sentence, of three months, to a thirty-eight-year-old bookmaker who had tried to slip across the border at Coolangatta with his two clerks. In that case, the evidence appeared to show an intention to evade quarantine controls at Wallangarra, the centre of Queensland’s border control efforts.

The quarantine and isolation measures introduced during the Spanish flu were resented most famously by rebellious soldiers, and inconsistencies in rules across the country and disunity among the states and the Commonwealth didn’t help. Indecision by the quarantine and port authorities lay behind an alleged mutiny by returning soldiers on an overcrowded vessel, the Somali, in Adelaide. The mutiny might have consisted of little more than threats by soldiers to row themselves ashore, but it resulted in the arrest and court martial of the federal Labor member for Adelaide, Edwin “Gunner” Yates. Yates’s trial was no mere formality, but his able young counsel, Alf Foster, couldn’t save him from conviction and sixty days in detention.

In spite of cross-border transgressions and unhappy returning soldiers, the necessity of quarantine was largely accepted at the time. With a lower death rate than in neighbouring New Zealand, and well short of the catastrophic eruptions in places like India, Australia was relatively fortunate. Geographic isolation, assisted by maritime quarantine and some state-imposed restrictions, undoubtedly helped save lives.

Epidemics have patterns — they fall unevenly on populations, on regions and over time. Australia’s epidemic was no different. Having arrived late here, infections peaked more than a year after the virus had washed through most other continents in the second half of 1918. Instead, “Spanish flu” was a 1919 experience for Australia.

The epidemic’s sudden arrival in Melbourne and Sydney in January touched off a rapid increase in deaths over the next three months. Every state subsequently experienced two waves, with a short intervening period. But the first impact was spread over a number of months in different states.

In spite of the somewhat fractious political climate, all states came to be declared as quarantine areas, beginning with New South Wales and Victoria in late January. South Australia’s declaration came a week later, Queensland not until May, Western Australia in June and Tasmania, the last, in August. This administrative history maps onto the mortality calendar in 1919, with a first peak in April, a short period of decline through May and then the greater impact in the middle of the Australian winter in July. By the end of the year few deaths were being recorded.

New South Wales was the state most affected, not only in absolute numbers but per head of population. Tasmania — conventionally regarded as having survived best because of its maritime isolation — had a mortality rate no different from that of South Australia. All states except Victoria closed their borders at one time or another, despite the view of the Commonwealth director of quarantine’s view that such closures would be futile, impossible to monitor and potentially dangerous because they involved ill-equipped quarantine facilities at rural outposts like Wallangarra.

Queensland’s determination to close its borders and prosecute transgressors like Frederick Sladen didn’t save it from a mortality rate much the same as Western Australia, though still below that of Victoria and New South Wales. The states mostly relied on light policing, with only Queensland appearing to have resorted to exemplary imprisonment of a few. In Sydney, zealous policing of mask regulations in early February led to hundreds of fines.

Trouble would come later for a state government that found it had exceeded its powers, however. In November the High Court upheld an appeal by hoteliers against prosecutions for breaching trading restrictions in New South Wales. And in December a Balmain doctor who had been committed for trial in February after breaching mask regulations was awarded £150 damages by a jury that agreed he had been falsely imprisoned by a Sydney magistrate. The doctor’s lawyer was future High Court judge and Labor leader, H.V. Evatt. In the end, the states’ regulatory powers remained contentious, as did the level of police enforcement needed to protect the community.

New South Wales eased its restrictions after April, only to find the epidemic return more fiercely in winter. The postponed Peace Ball at Sydney Town Hall in early June was subsequently blamed in the press and by public health authorities for adding to the spread of infection.

Just as national figures disguise a different story in each state, so were the epidemic’s effects different across the population generally. The influenza of 1919 especially affected young men up to the age of forty, and even more so if they were working class-men living in the poorer and inner-city suburbs of Sydney. In Queensland, the greatest impact fell on Aborigines. The chief protector’s annual report for 1919 revealed that at least 298 Aboriginal people had died, making up more than a quarter of the state’s deaths from influenza and constituting a death rate up to nine times that of the general population. Western Australia’s protection regime appears to have prevented significant Aboriginal mortality in that state, but in Queensland Aboriginal workers who became sick on farms and stations were sent back to their home settlements only to pass on the virulent infection.

The differences in global, medical and political context over the span of the past century raise questions about whether we can learn much from the Spanish flu pandemic. Much was changed by its impact — in stimulus to medical research that eventually uncovered its cause to be a virus rather than bacterial, and in the development of medical and hospital systems to better cope with infectious diseases — so there’s some point in revisiting the evidence to estimate what accelerated or limited its spread. In particular, though, the fact that all states, and especially New South Wales, experienced a more damaging second phase after restrictions were lifted is an ominous reminder of the risks of impatience in the face of an epidemics. •

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What has been learned and how is that knowledge being used?

The story of the origin of the coronavirus pandemic is now fixed in the public mind. In late 2019, it goes, a new virus was generated as wild animals (pangolins are often invoked) and humans came together in the Wuhan wet market.

In reality, we don’t know exactly what happened — and it is important to trace the genesis of this virus because it’s the key to stopping the next pandemic. It now seems most likely that the coronavirus originated in bats, which are natural reservoirs for viruses. But we still don’t know which species served as an intermediate host before the virus moved to humans. Bats were where the 2002 SARS outbreak started, moving to civets before infecting humans. As the detection of the new virus in pets and a tiger in the Bronx zoo shows, coronaviruses like SARS-CoV-2 are circulating all the time in the animal kingdom.

There is definitely some sort of connection to the Wuhan wet market, which was the first epicentre of the pandemic, but the first recognised case in Wuhan had no clear link and pangolins are unlikely to be involved.

How and when the virus arrived in the United States is also unknown. Recently released evidence overturns the idea that the first infections were in a Washington state nursing home and the first coronavirus-related death in Seattle on 29 February, shifting the timeline of the virus’s spread to weeks earlier. Two Californians who died in their homes in early to mid February were infected, which means the virus was circulating in California for at least a month before it was detected in Washington state.

New York City announced its first confirmed Covid-19 case on 1 March, but modelling suggests nearly 11,000 people in the city could already have been infected. Moreover, genetic analyses show that most infections in New York came from multiple locations in Europe rather than directly from China. No one then was paying attention to the planes flying into New York from these locations.

This undercover start — and subsequent difficulties in containing it in countries like the United States, Italy and Spain — reflects Covid-19’s long and variable incubation period (the time between exposure and first symptoms is typically five to six days but may range from two to fourteen days) and the fact that some infected people have only very mild symptoms or none at all. Recent studies suggest about 40 per cent of those infected are “silent carriers,” although one study from China put this as high as 80 per cent.

Children and young, healthy people seem more likely to be asymptomatic, but it is unclear if this also means they are not infectious. French researchers found one child who was simultaneously infected with coronavirus, influenza virus and the common cold. Both of his siblings caught the latter two viruses, but the research subject didn’t pass coronavirus on to either of them, nor to any of the other 172 people he had contact with.

A small study by the National Centre for Immunisation Research and Surveillance came to the same conclusion — that children are unlikely to transmit coronavirus between each other or to adults. This report is being cited by the federal government as it advocates the reopening of schools.

Infectious disease experts are still trying to understand this variability in who gets infected and who shows symptoms, but the lesson learned is that widespread testing is essential to understand the full extent of infection in the community.

The SARS-CoV-2 virus is most commonly found in the upper respiratory tract and in fluids from the lungs. It spreads primarily through infected droplets generated by coughing and sneezing, or when hands touch surfaces or objects contaminated by these droplets and particles. Some studies have suggested that aerosol transmission is plausible, though others dispute this.

It is not clear whether pregnant women can pass the infection on to their babies. While several cases of newborns with coronavirus have been reported, no traces of the coronavirus have yet been found in the placenta or the umbilical cord, making it unlikely that a mother can infect her child while it is still in the womb. This could change as more information becomes available.

Viable, infectious SARS-CoV-2 has also been isolated from blood, urine, and faeces. It is not yet known whether other non-respiratory body fluids from an infected person — vomit, breast milk or semen, for instance — can be sources of infectious SARS-CoV-2.

Infectivity is measured by the reproduction number (the number of people an infected person will pass the illness to). For SARS-CoV-2 this is 2.0 to 2.6 – higher than the flu (1) but considerably less than measles (15). Scientists don’t know how many virus particles of SARS-CoV-2 are needed to trigger infection, and the extent to which viral load is an indicator of the severity of disease is unclear. Two studies in the Lancet reported that people who develop more severe pneumonia had, on average, higher viral loads when they were first admitted to hospital; but another study found that some asymptomatic patients had similar viral loads to patients with Covid-19 symptoms.

The virus enters the body through the mucous membranes of the face (eyes, nose and mouth), which provide a direct pathway to the throat and lungs. The path from the point of infection varies enormously and is determined by each individual’s immune system.

About 80 per cent of people with Covid-19 recover without needing any specialist treatment. But sometimes, even in otherwise healthy patients, the immune response is excessive or prolonged and causes what’s known as a “cytokine storm.” In these cases, the inflammation and organ damage can be fatal.

The most common cause of death in people with Covid-19 is acute respiratory distress syndrome, or ARDS, the result of a build-up of fluid in the lungs. Elderly people and those with chronic lung disorders are more likely to develop ARDS. A predominant theory is that these patients have increased levels of angiotensin converting enzyme 2, or ACE2, which acts as a receptor for the virus. There is confusion about whether the infection is amplified by a class of drugs used to treat hypertension that affect ACE2 levels and are often taken by patients most susceptible to coronavirus.

Some evidence also suggests that in severe cases, the virus may enter the brain through the olfactory nerve in the nose and damage that part of the brain that controls breathing.

One of the most shocking aspects of this pandemic is how people become so ill so quickly. Clinicians are just beginning to recognise that Covid-19 pneumonia initially causes a form of oxygen deprivation called “silent hypoxia” because it is insidious and hard to detect, and patients don’t feel short of breath. By the time their situation is recognised, patients’ oxygen levels are seriously compromised. Then the only treatment is mechanically to take over the patient’s breathing. Simple monitoring of blood oxygen levels can prevent this.

A striking feature of Covid-19 is that it disproportionately affects males. A meta-analysis of 206,128 cases around the world found that, although the number of infections was roughly equal between sexes, men were more than twice as likely to get so sick they needed intensive care and about 60 per cent more likely to die.

Two previous emerging coronavirus diseases, SARS and MERS, also disproportionately affected men, as, to a lesser extent, does influenza. This may be related to the very different immune systems of men and women and/or hormonal differences. Some have proposed a role for smoking, as smoking rates are universally higher in men. Another possibility is that men — especially older men — are in generally worse health than women. When the authors of a New York study factored prior health status into their analysis, they found that sex was no longer one of the main risk factors for severe Covid-19.

A prime risk factor for severe complications from Covid-19 is obesity. Although people with obesity frequently have other medical problems (such as heart disease and diabetes), studies indicate that obesity in and of itself is exceeded only by age as the most significant risk factor — and, surprisingly, is more important than asthma and other chronic respiratory conditions — for hospitalisation. Young adults with obesity appear to be at particular risk.

It is postulated that in coronavirus-infected patients with obesity, there is greater inflammation of adipose tissue, the fatty layer under the skin and around internal organs, and this contributes to immune activation, an enhanced cytokine storm, and increased virus shedding. There is a view that obese people shed virus for longer and that their quarantine should therefore be longer.

A shocking aspect is the racial disparities seen in coronavirus hospitalisations and deaths, especially obvious in the United States and Britain. Data from the US Centers for Disease Control and Prevention show that the rate of recorded Covid-19 deaths among African Americans (92.3 deaths per 100,000 population) and Hispanics/Latinos (74.3) were substantially higher than for white (45.2) or Asian (34.5) Americans.

Reports from cities including Chicago, New York and New Orleans indicate even greater racial disparities in death rates. A Washington Post headline described the virus “ravaging one of the country’s wealthiest black counties.” The situation appears to be worse for Native Americans living on tribal lands. Of the first 2249 patients with confirmed Covid-19 in Britain, 35 per cent were non-white, much higher than the proportion of non-white people in the population. Sadly, the fate of many patients, especially people of colour, is sealed by pre-existing social determinants of health and established racial inequalities.

While there is growing understanding of the risk factors and causative mechanisms of Covid-19 disease, this has yet to deliver a vaccine to prevent it or pharmaceutical treatments for the pneumonia it causes.

In desperate bids to find these treatments, researchers, clinicians and pharmaceutical companies around the globe have launched a raft of studies and clinical trials investigating experimental drugs, a decades-old malaria medicine, a veterinary drug that also kills head lice and the parasites that cause river blindness, and cutting-edge therapies that have worked for other conditions such as HIV and rheumatoid arthritis.

The value of this work is undermined by a lack of national, let alone international, strategies, leading to overlapping efforts and an array of small-scale trials that will not lead to definitive answers. No agreements have been reached about how to prioritise efforts, which data to collect and how to share findings to get answers faster. It’s been described by one observer as “chaotic.” A key hedge to the many trials is that there is no recognised “standard of care” against which to compare the drugs being studied.

Such results as have been delivered to date are, not surprisingly, either negative or inconclusive. Regulators have warned about the risks of the malaria drug hydroxychloroquine (much promoted by Donald Trump), and early reports from clinical trials of this drug and Remdesivir (a failed candidate for treating Ebola) have been damning, although other studies are still under way. Published results from a trial of the combined antiretroviral drug lopinavir/ritonavir also showed no improvement in clinical outcomes. A study of the head lice drug ivermectin is proceeding despite warnings that the dosage needed to kill coronavirus is up to one hundred times higher than approved doses.

The real quest is for a vaccine to prevent infection. Many vaccine prospects are being explored using a wide range of research approaches. Fortunately, the international cooperation has been much greater than for pharmaceuticals, as evidenced by the work of the Coalition for Epidemic Preparedness Innovations. One survey of the Covid-19 vaccine development landscape found 115 vaccine candidates. Of the seventy-eight confirmed active projects, seventy-three are currently at exploratory or preclinical stages and only a handful have moved into clinical development and testing. Hanging hopes on the development and large-scale production of a safe and effective vaccine within the next few years is an exercise in unbounded optimism.

As a way of buying time, researchers in four countries will start a clinical trial of an unorthodox approach testing the century-old BCG vaccine, used against tuberculosis, to see if it can generate a non-specific immune response that will fight off the coronavirus. Options for repurposing other vaccines are also being explored.

Most research funding is being spent on finding a vaccine and effective drugs. That effort is vital, but it must be accompanied by research on how to target and improve the non-drug interventions that are the only effective interventions so far.

The only established treatment for Covid-19 is supportive — basically the provision of oxygen via masks, respirators, ventilators and, in extreme cases, extracorporeal membrane oxygenation to help maintain high oxygen levels until patients’ lungs have recovered sufficiently for them to function normally.

These latter two treatments are resource-intensive and expensive forms of life support, with the potential for causing severe complications including infection and haemorrhage. Ventilating patients with Covid-19 seems to drive the infection deeper into the lungs and saves few lives. Avoiding the use of a ventilator is better for both patients and the healthcare system, so there is an urgent need for controlled clinical trials of ventilation versus non-invasive oxygen therapy in these patients.

In terms of prevention, the only approaches currently available require physical isolation, hand hygiene and protective equipment like masks. These interventions have been assessed by only a handful of studies, most of which have been assessed as of low quality or small sample size.

Work is under way to understand if the levels of immunity in individuals and the population after infection are protective, and how long that immunity could last. With no widespread inherent immunity to a new virus like SARS-CoV-2, scientists are starting from ground zero.

Doctors examining the blood of patients recovering from a Covid-19 infection are finding that fairly high levels of neutralising antibodies are made by the immune system. These antibodies coat an invading virus at specific points on its surface, blocking its ability to break into cells and thus conferring immunity. Most virologists believe that immunity against SARS-CoV-2 will last only a year or two, in line with other coronaviruses that infect humans. That means that even if most people do eventually become exposed to the virus, it is still likely to become endemic, with seasonal peaks of infection.

Current antibody tests, which show who has been infected, are often inaccurate, and it is not clear whether a positive result signals immunity to the coronavirus. The World Health Organization has warned against relying on these tests for policy decisions such as the introduction of “immunity passports.

It is possible that antibodies can be turned into therapies. Plasma containing the antibodies from recovered patients is transfused to gravely ill patients in an experimental treatment known as convalescent plasma therapy. Early results from a small number of Chinese patients, published in late March, were promising. Doctors have been using convalescent plasma transfusions to help patients fight diseases as far back as the Spanish flu of 1918. More recently, the procedure has been used in patients with SARS, Ebola, and H1N1.

Both vaccine development and plasma therapy depend on the virus not mutating in a way that modifies the shape of its antigens. Several studies have also established the relative stability to date of the SARS-CoV-2 genome, perhaps because the virus is encountering few immune hosts who could halt its spread.

Researchers have shown that two major strains of SARS-CoV-2 now exist. The newer and more aggressive L type accounts for about 70 per cent of the analysed cases, while the rest are linked to the older S type version. The mutations don’t seem to have affected the S1 spike protein, which is the antigen most people are targeting for vaccine production. But another study from China suggests that the virus’s ability to mutate has been vastly underestimated, providing laboratory evidence that certain mutations could create strains deadlier than others. Much more research is needed in this area, including monitoring virus samples from different locations over time to track mutations.

Finally, what do Covid-19 recoveries look like, and what are we to make of the host of side effects that are now appearing? On these questions, evidence is thin.

The recovery path for Covid-19 patients is very slow. Most cases recover within three weeks, but they can take much longer and be much more complicated and less linear for the sickest patients. Weaning patients off ventilators can take several weeks, and patients who have been in intensive care can experience delirium and symptoms of post-traumatic stress syndrome.

Once thought to be a pathogen that primarily attacks the lungs, the virus now seems to inflict long-lasting damage on many of the body’s organs. Reports are coming in of kidney damage requiring dialysis; strokes, even in young people who had only mild symptoms; Guillain–Barré syndrome, blood-clotting complications; neurological problems; and liver and intestinal damage. Doctors in Britain, Italy and Spain have been warned to look out for an inflammatory condition (perhaps the rare Kawasaki disease) in children, which is possibly linked to coronavirus. For many patients, surviving Covid-19 means a long road back to health.

How the pandemic ends will depend on medical advances still to come and perhaps yet to be predicted. In the interim, for communities and nations, surviving depends on individual behaviours and compliance with evidence-based guidelines. •

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Initial estimates of the number of downloads needed for COVIDSafe to be effective have also been walked back. While a high take-up rate is needed to capture the network dynamics that will give the app real power, even lower levels of coverage will presumably provide some assistance to the manual process of contact tracing that has thus far been the mainstay of Australian epidemic control efforts.

By linking the end of physical distancing and the resumption of full economic activity to the extent of COVIDSafe’s take-up, the government is embarking on an unusually explicit exercise in collective social responsibility. If nothing else, it will highlight the extent to which everyday life depends on civic mutuality. The debate about the app has also vastly increased awareness of the normally hidden privacy issues that underlie every online exchange: exactly the type of explicit attention that Europe’s General Data Protection Regulation, or GDPR, was aimed at.

In the process, two models are fighting it out: one in which personal data exchange is subject to informed consent as part of a social bargain freely entered into; the other in which shadowy corporations collaborate with state apparatuses to maximise covert surveillance. The Australian government is seeking to position COVIDSafe within the first; its opponents fear it is a version of the second.

Those concerned about opaque surveillance viewed with alarm the news that a company called Palantir is involved in creating Covid-related data-management systems for a slew of health systems, including Britain’s National Health Service and the US Department of Health and Human Services. Palantir is about as controversial as a data-mining company can get: founded with money from the CIA’s venture-capital arm, it provides services for arms manufacturers, defence departments and counterterrorism operations, was behind the Los Angeles Police Department’s attempt to implement “predictive policing” by profiling potential criminals so well that they could be stopped before crimes were committed, and extended the capacity of US Immigration and Customs Enforcement to carry out deportations. For Palantir’s opponents, the cherry on the cake is that its founder, Peter Thiel, is Donald Trump’s most prominent Silicon Valley supporter.

At the core of Palantir’s value proposition is that it will put together vast amounts of disparate information faster and better than anyone else, a feat that is especially important when faced with disruption, whether from terrorists or viruses. “Taking control of complex systems” is identified by Palantir as the key task in the face of the Covid-19 pandemic: “leaders must roll up their sleeves, demand the information required to build a common operating picture, and take back control of the decisions.” And, needless to say, Palantir can help: “this is a problem that can be addressed by smart deployment of technology to augment and support institutional decision makers and the critical analysis they need to carry out to make sound decisions.”

This narrative of taking control faces a counter view that sees control as a dangerous fantasy. Andy Stirling of Britain’s Social, Technological and Environmental Pathways to Sustainability Centre makes the case strongly:

There is of course no shortage of apparently effective instruments available to seemingly controlling “cockpits”: dispassionately assured experts; precise scientific metrics; rigorous technical models; massive hierarchical agencies; apparently all-seeing monitoring; seductively informative graphics; compellingly captivating dashboards; reassuringly evidence-based plans; commanding policy levers; invisibly nudging techniques; formidable military capacities; all presided over by our “natural leaders” in the same old “seats of power.” But in reality, what the pandemic already seems to show is not only that there is no pilot… but that the “cockpit” itself has been built largely in our imaginations.

Underlying this view is an ecological model of complex adaptive systems. Here, systems are just as much a focus as in the control model, but much less faith is placed in finding the levers of control that can adjust system properties while avoiding unintended consequences.

Universally adopted apps are just the latest version of an all-seeing panopticon as an instrument of control. But, as Michel Foucault proposed, the disciplinary power of Jeremy Bentham’s panopticon — the prison design that has all the prisoners’ cells in a circle facing the central watchtower — was not that it enabled each prisoner’s behaviour to be corrected through direct observation but that it was the mere possibility of being observed that led prisoners to correct themselves. This transition from external control to self-government became the prominent theme of Foucault’s later work on the operation of power in advanced liberal societies.

Looking at the reports of police-issued fines for breaches of lockdown laws in Australia and elsewhere, you might think that external control is far more important than self-government. But the eruption of civil disobedience in some countries suggests that the power of policing to impose authority from outside is limited in its scope and duration.

It is now dawning on citizens in many places that social regulation in the face of the pandemic will continue not just for days or weeks, but for months to come. Even under the most optimistic scenarios of control and near elimination in a few countries like Australia and New Zealand, the smallest outbreaks will need to be detected, the immediate vicinity quarantined, contacts traced, tests made widely, and the arrival of foreigners strictly controlled. These social technologies will need a high degree of popular support, and the negative impacts of distancing will need to be counteracted by increased, and very local, solidarity.

Most crucial will be the need to counter the tendency to “othering,” or locating the threat in those who are different. This is a story we know well from AIDS: I remember seeing an interview with a drug user imprisoned in Russia — a country whose refusal to adopt harm-reduction policies drove the major and still-growing HIV epidemic there — explaining that the saving grace was that they didn’t have HIV in his block, unlike the block over there, he added, gesturing across the footpath. Enacting imaginary boundaries is both futile and counterproductive in an epidemic.

Elsewhere, a magisterial review of the social and behavioural science literature on Covid-19 responses, initiated by New York University’s Jay Van Bavel, is available as a preprint version. In themselves, the 255 articles it covers would constitute a fine curriculum for a course on social responses to emerging diseases. Given the first version of the article was pulled together in a week, the fact that all but two of the fifty-plus authors are from rich English-speaking countries is excusable: its amplification to a wider range of global voices is surely on the agenda.

Among its key take-home messages is that the creation of shared social norms is critical in changing social conduct. The indirect effect — my view of what I think my neighbour is doing — may be more important than anything else. The authors show the vital importance of “dyadic, synchronous” connection — in other words, communicating in real time with real friends one-to-one, whether in person or on a device, is vastly more important than message posting.

They also suggest that it may be possible to inoculate against fake news by seeding false stories and using them to generate understanding about the ways misinformation circulates. But, perhaps most crucially for Australia at this time, they suggest that it may be maladaptive for countries to promote their successes compared with other countries. This type of “collective narcissism”

is associated with a greater focus on defending the image of the country, rather than on caring for its citizens. It is also correlated with seeing out-groups as a threat and blaming them for in-group misfortunes. To increase a willingness to take a pandemic seriously and engage with other nations to defeat it, citizens and leaders may need to accept that their country is at risk, just like others, and find ways to share resources and expertise across national boundaries.

That message was amplified across the globe last weekend in the mammoth “one world together at home” concert in support of the World Health Organization’s efforts against the pandemic. Assembled by former Young Australian of the Year Hugh Evans, co-founder of Global Citizen, together with Lady Gaga and her mum, this unique streaming concert brought together just about every musical big name.

Its parallel in the world of policymaking was the launch of the ACT Accelerator, a global collaboration to advance the development of Covid-19 tools and therapeutics and ensure their availability to all.

As the paradigm shifts, we can see the links between local acts of mutual support, the coordination of national activity while avoiding the hubris of total control, and effective mechanisms of global solidarity. This is where we need to invest our energies. •

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Two things stick in my mind from that meeting. One was the call by economist Jeffrey Sachs to imagine what an AIDS response would look like if no resource constraints existed. At the time, estimates of the funds needed to tackle AIDS in low- and middle-income countries diverged wildly — the World Bank thought US$300 million was as much as countries could absorb; the price tag from some activist scientists went as high as US$40 billion. To cut through this fog, Sachs insisted that the first task was to specify what was needed without thinking about the cost, and only then make estimates of the necessary outlays.

The second notable presentation was by leading British epidemiologist Sir Roy Anderson. Epidemics always proceed in waves, he advised, with the first wave peaking as the most susceptible are affected. Thereafter, the overall curve may decline but it is actually made up of innumerable individual waves, as the virus colonises and passes through a new group or territory. The crucial question, therefore, is the steepness of the decline on the other side of the first peak, and how much the curve stays down as the further waves hit.

Fast-forward to December 2010, when UNAIDS introduced a new strategy and a new slogan: getting to zero. It called for zero new HIV infections, zero AIDS-related deaths and zero discrimination. The germ of this idea came from Laurie Garrett, world-renowned oracle of emerging pandemics. Why not put a great big zero on your next report, she suggested to UNAIDS. The slogan struck the right note, and proved very popular at country level. (It sometimes got lost in translation, though: I remember receiving a fancy document holder from a national AIDS authority proudly emblazoned with the message “Getting Zero.”)

The new goal inaugurated a debate about “the end of AIDS” that continues to be controversial, with some people — including Piot, post-UNAIDS — arguing that the goal remains so distant it is misleading to raise the hope. It also focused much closer attention on the concept of disease elimination.

Epidemic management has a hierarchy of terms. At one end is mitigation, when efforts are made to reduce the worst effects of the disease without any hope of modifying its spread. Then there is control or suppression, when the drivers of the disease are sufficiently understood and the capacity exists to manage its spread, slowly bringing the number of new cases under control. Then there is elimination, when the disease is so tightly controlled in a given territory that health authorities can assert with confidence that new cases of the disease are not present. And finally there is eradication, when the virus or pathogen that causes the disease dies out because it has no human hosts — a feat achieved with smallpox and almost with polio. (Getting rid of the last hundred cases takes about as much effort as the previous million.)

Malaria provides a good example of elimination efforts, and island nations have been ideal test cases. In 1867, a few years after the disease was introduced into Mauritius, a virulent epidemic killed one-in-eight islanders. Control efforts and quinine distribution gradually limited its spread, and a major elimination campaign from 1948 to 1951 reduced cases by more than 95 per cent. Eventually, in 1968, the last local case was detected, and WHO certified Mauritius malaria-free in 1973.

But when Cyclone Gervaise devastated the island in 1975, the combination of new mosquito habitats and an influx of reconstruction workers allowed a new malaria epidemic to take hold, peaking in 1982. The elimination effort began all over again, with the last case of indigenous malaria recorded in 1997. Even now, Mauritius maintains constant vigilance, with a multimillion-dollar program of surveillance, incoming passenger screening, and obligations on residents to participate in environmental management.

Eliminating malaria with a combination of vector control, effective treatment and cheap prophylaxis is a doddle compared with the task we face given our current knowledge of Covid-19 (and the fact that no fully effective malaria vaccine exists even after generations of effort gives pause for thought). That history, and the history of other epidemic responses, suggests that health authorities in Australia and New Zealand are right to be cautious about declaring a goal of elimination. They know that even were elimination to be achieved, its cost would be eternal vigilance.

As we have all become aware, public health judgements are exercised in conditions of uncertainty, even after all the expert parameters are taken into account. My gut feeling is that elimination is not achievable in current conditions in Australia, and even as reported new cases sink to zero, patches of undetected transmission will still occur, waiting for the right conditions in which to bloom into a renewed spread.

Seasons look likely to play a part. A Harvard team’s modelling of the post-pandemic spread of Covid-19 draws attention to seasonal dynamics that could affect transmission. Not only do they conclude that social distancing measures will be needed until 2022, they also suggest that recurrent wintertime outbreaks will continue to occur, with the greatest severity when outbreaks are established in autumn/winter. That possibility will no doubt propel Australian authorities to an even more cautious approach as winter approaches the southern states.

Meanwhile, the United States has proposed a robust set of criteria to be applied before phased “comeback” can take place. As well as reductions in symptoms and cases over a fourteen-day period and the capacity to treat all patients routinely, it includes a measure to determine “downward trajectory of positive tests as a percent of total tests within a fourteen-day period (flat or increasing volume of tests).” This metric cleverly gets around the incentive to reduce case detection as a means of decreasing the apparent size of the epidemic.

However robust, these criteria may be moot if civil disobedience becomes the main modality of epidemic coping. What may emerge instead is a de facto natural experiment. It will provide rich material for retrospective analysis but no comfort at all to those whose loved ones are lost.

Civil disobedience goes hand in hand with the negative spiral of blame shifting, which means that phylogenetics might be taking over from epidemic modelling as the next fad in armchair science. You can pick Nextstrain.org or choose Cambridge, with very different conclusions. While phylogenetics provides interesting insights into disease origins, it isn’t much use in responding to a pandemic as it is unfolding.

We know that perfect hindsight is no superpower in an epidemic. The first AIDS bestseller, Randy Shilts’s 1986 book, And the Band Played On, included a breathless account of Gaëtan Dugas, labelled as AIDS’s “patient zero.” Shilts garnered plaudits for his robust account of US government indifference and infighting, but even at the time his search for patient zero was questioned. That part of the book holds up even less well now that we know that the origins located at the time were way off track and provided no help in ramping up the AIDS response in the United States and globally.

Much more pertinent is close attention to the spread’s shifting dynamics alongside likely types of treatment. Here, one of the past week’s more interesting papers on the clinical management of Covid-19 suggested that a “disease tolerance” perspective was needed: “Instead of asking ‘how do we fight infections?’ we might start asking ‘how do we survive infections?’” Rather than targeting the pathogen, this perspective changes to ways of limiting damage to the host.

As Susan Sontag cautioned, rendering diseases in terms of metaphor is always dubious. But bearing this caution in mind, it is not far-fetched to say that our focus really needs to be on how we survive this pandemic in the weeks ahead, rather than on rehashing the steps that led us to where we are now.

“If we only knew then what we know now” is a forlorn cry. Back in 2001, if the world had known how much of the AIDS epidemic was still to come, there would have been no hesitation in adopting Jeffrey Sachs’s resource-unconstrained response. Let’s not make the same mistake today. •

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As a health educator, I learned early on that different people have enormously different capacities to tolerate uncertainty. Some greet it with fatalism, shrugging their shoulders and continuing their daily routine. Others grip their keyboards with white knuckles, consuming every bit of news and trying to make it all fit together. As people in that second group find gaps or contradictions, they convince themselves that someone is either lying or incompetent. From this, we get the vocal insistence — despite all evidence to the contrary — that Australia has a secret policy of “let it rip” that would tolerate 3 to 5 per cent fatality rates to build up herd immunity.

The core of this mindset is the belief that someone, somewhere, knows everything and can control everything. Yet we live in complex systems in which nobody ever has complete knowledge or full control, and unexpected outcomes can emerge from behaviours enacted with quite different goals. In my own research, I use complex systems theory and methods to visualise and understand different social forms, including personal networks, organisations, cultures, communities, markets and policy spaces. One finding is constant: complexity teaches us we need to get used to uncertainty.

Right now, though, we are hearing from economists and think tanks and opinion writers and even medical journal editors, arguing that we must choose between two strategies, stick to just one option or focus on only one variable, or claiming that expert discipline X lacks a perspective only available to discipline Y or that experts can’t resolve it and simple models are all we need. At the end of March, for instance, the Medical Journal of Australia published a very simple model, based on Italian data, that predicted exponential growth in demand for intensive care beds in Australia. An accompanying editorial said that under conditions of complexity and uncertainty (anything involving human behaviour) “simple models may be more robust; at least early on, when they matter most.” And yet, in the fortnight that followed, the epidemic curve slackened and bent, invalidating that “robust” model. As H.L. Mencken observed, for every complex problem there is an answer that is clear, simple and wrong.

As epidemiologist Kathryn Snow has explained in the Guardian, more sophisticated models use data from observations of the real world to construct simulations within which we can experiment with different policy measures. The simulation isn’t a complete representation, of course. An attempt to model society in its full complexity would run into two insuperable problems: it would take too long to collect comprehensive data, making any answers out-of-date; and even if we had all that data, including so many variables would generate so many possible combinations that the simulation could not be computed at all.

In the aftermath of the global financial crisis, ecological scientists were brought in to survey the wreckage of the mainstream economic models that failed to predict the crisis even as it unfolded. Even in financial markets, where we do possess complete and timely knowledge of holdings, transactions and prices, these appraisals suggested that even with the most innovative models we can only make reliable predictions over a time horizon of a day or two, at most.

And yet we make plans for the future. We pass a budget, we make legislation, we plan a strategy involving a suite of measures in response to the local offshoot of the Covid-19 pandemic. If we can’t predict what will happen, and when, then how can we do any of that?

Coping with uncertainty involves taking action as a way of knowing. We make decisions based on all the insights available to us — not just models, surveillance data and peer-reviewed publications, but also things like professional experience, comparisons with other settings and anomalies observed in practice. The action we take and the effects we observe help us to better understand the system we are engaging with.

As a complex system, nothing about an epidemic is required to seem logical. The bulk of it is unseen: a virus moves through cells in organs in bodies and via encounters and relationships in networks and communities in populations. Minor coincidences can cause explosive, unpredictable outcomes — a food service worker, highly infectious but not yet feeling unwell, infects three dozen guests at a single cocktail party. Similarly, the diversity of people in a social network can determine whether an infection stays localised or travels across communities, countries and even continents. All of these factors can interact and drive significant changes in an epidemic without giving any advanced warning.

This requires us to be responsive — to pay close attention to all the different sources of knowledge available to us, and to be open to improvisation and adaptation. When members of the community and the commentariat understand this, they can see why we might shift from one strategy to another, and they do better at applying general recommendations to their own circumstances. This makes communicating the rationale absolutely vital. The demand for certainty is a barrier to a responsive strategy for epidemic control.

This is why it’s so encouraging to see deputy chief medical officer Paul Kelly talking about the endgame while the premiers are cautioning against expecting a return to normal life anytime soon, and the NSW chief health officer Kerry Chant talking about a “zigzag” approach to lifting restrictions while the modelling experts warn that easing up too soon might provoke “explosive resurgence.” As Harvard epidemiologist Mark Lipsitch says, “I think there’s going to be a lot of experimentation, not on purpose, but because of politics and local situations.”

These are not inconsistencies to be seized on or mutually exclusive positions to be debated in abstract terms. We can’t answer when restrictions might be lifted, but our governments are beginning to communicate how that might happen and what we might all need to be ready for, recognising that the pandemic, and our epidemic, will continue to evolve. •

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But the escalation of Trump’s attacks on the WHO — directly proportional to the intensifying scrutiny of his own inept response to Covid-19 — makes it hard to avoid the topic, especially as Australia might find it challenging to distance itself from the American president’s stance.

Of course, I am not a disinterested observer. I worked for sixteen years for the multilateral organisation UNAIDS, whose dozen co-sponsors within the UN system include the WHO. The UNAIDS office in Geneva shared a building with staff from WHO headquarters across the road. Before joining UNAIDS I advised the WHO on a couple of projects. And I have many friends and colleagues who work for the WHO.

Regardless of my background, though, I think a strong case can be made against the two central allegations: that the WHO is too pro-China and that it was slow to call the pandemic.

The WHO’s earliest responses to the news of a novel coronavirus outbreak in Wuhan were careful to praise the Chinese authorities for their handling of the outbreak. The strategic reasons are simple: if an epidemic of potentially global significance is breaking out, you want the cooperation of the country in which it has emerged. In this case, there was also strong evidence that the Chinese authorities had learnt from SARS and were keen to support global transparency and sharing of information .

Critics point to Taiwan’s exclusion from the WHO at a time when that country’s response to Covid-19 is apparently among the world’s more successful. The WHO wants to pretend Taiwan doesn’t exist, say its critics, and is thus depriving the rest of the world of vital information about effective responses. In reality, the WHO’s position simply reflects the international diplomatic settlement known as the One China policy, which emerged in the early 1970s.

Ever since the UN vote in October 1971 that switched China’s seat at the United Nations from the Republic of China (Taiwan) to the People’s Republic of China, it has been the government in Beijing that has represented China in all UN bodies, not just the WHO, with the acquiescence of all the major powers. That hasn’t stopped Taiwanese journalists using the current crisis to try to trap WHO representatives into publicly conceding Taiwan’s status independent of China.

In reality, the WHO finds ways of working with Taiwan by keeping exchanges of information at the technical level. A global pandemic is not the time to push a reversal of the One China policy, and the irony of the recent debate is that it has made routine technical communication more difficult.

The WHO’s advice on the closing or reopening of “wet markets” has also been adduced as evidence of its pro-China bias. The term itself and its application exclusively to Asia indicates a desire to locate new disease threats in exotic, foreign and bizarre locations. Lurid pictures of snakes being cut up on chopping blocks and mysterious pots of meats darkly stirred are grist to this mill. The Australian politicians who say they are flabbergasted at calls to reopen “wet markets” don’t appear to be outraged by trading continuing at the Sydney Fish Market or Melbourne’s Queen Victoria Market. Unsurprisingly, the WHO has called for produce markets that are the main source of food to be open, with close and careful regulation of markets at which any live animals are sold.

The second charge against the WHO, also wrapped up with attacks on China, is that it acted too slowly. While conspiracists refer to intelligence reports of disease outbreaks in Wuhan as early as November 2019, the verified record suggests that a cluster of viral pneumonia of unknown cause was identified in Wuhan on 21 December 2019, and that Chinese authorities conveyed information about the outbreak to the WHO China office on 31 December. That information was then published on the WHO website on 5 January 2020.

To enforce international cooperation in the face of an epidemic, the WHO uses the International Health Regulations, which allow it to declare a Public Health Emergency of International Concern, or PHEIC. The process of declaring a PHEIC was examined in minute detail by the WHO after the experience of the 2009 H1N1 flu pandemic, when many critics felt the WHO overstepped the mark and caused global alarm about a threat that turned out to be no more serious than a seasonal flu epidemic.

The WHO was therefore determined to marshal unimpeachable evidence in its handling of Covid-19. Its emergency committee met on 22 January to determine whether the outbreak met PHEIC criteria. After a day of deliberation the committee could not agree that it did, and convened for a second day to reconsider. Again, it advised that the criteria were not met, and suggested reconvening in ten days. That proved too long a wait, however, and WHO director-general Tedros Adhanom called the committee together again on 30 January, at which time a PHEIC was declared.

Many were calling for the WHO to describe Covid-19 as a pandemic, which it did on 11 March. But it should be noted that a pandemic declaration has no particular force in international law: “pandemic” is neither defined nor used in the International Health Regulations. The WHO issued a considerable number of pandemic influenza guidances in the context of its response to the 2009 H1N1 outbreak, and these are often taken to be the WHO’s pandemic rules, but their status is no more or less weighty than any other body of WHO technical guidance.

Because of the alarm it causes, the WHO doesn’t use the word pandemic lightly. Its use on 11 March was designed precisely to elevate the level of alarm.

The WHO has also been criticised for a reluctance to urge travel restrictions in response to the Covid-19 outbreak. This too has a long history of controversy, with opinion divided on the efficacy of closing international borders in the face of epidemic outbreaks. In declaring Covid-19 a PHEIC on 30 January, the WHO noted that its emergency committee “does not recommend any travel or trade restriction based on the current information available” but that countries have an obligation under the International Health Regulations to inform the WHO about any travel measures taken, and the public health rationale for them. At the same time, the WHO urged countries to “place particular emphasis on reducing human infection, prevention of secondary transmission and international spread.”

North Korea became the first country to close its borders, on 22 January 2020. Singapore and Vietnam closed down flights to Wuhan and, from 1 February, many countries started ratcheting up their travel advisories and, progressively, their travel restrictions.

The WHO’s reluctance to call for international travel restrictions is longstanding, and in apparent contradiction to its advocacy of social distancing including in the Covid-19 case. Part of the explanation lies in the view that closing borders is a mark of xenophobia rather than epidemic control, and part in the fact that border closures are almost always too late and can breed complacency. As the modelling studies of Covid-19 have shown, only a few “seeds” need to find their way through restrictions for an outbreak to occur.

The view that border closures are often too late is borne out by phylogenetic studies of SARS-CoV-2, which use mutations in the genome to tease out the history of a particular instance of the virus. Here, Nextstrain has proved to be one of the more useful tools developed during this pandemic. Building on thousands of virus genome samples deposited with an international registry, it has traced cases from the outset and mapped the spread. If you want to ponder the potential impact of border closures, pick your preferred date and adjust the time frame accordingly — it will show you how far the spread had already gone.

When Ebola broke out in 2013 in West Africa, the WHO was widely criticised for the inadequacy of its response. It was hamstrung by the unwieldy structure of politically appointed regional directors and country representatives overly subject to the national sensitivities of the countries in which they were based; headquarters was still smarting from criticism of its handling of the 2009 H1N1 pandemic; and the international community was barely raising a finger to support the countries affected. It was only when health personnel from wealthy countries began to be repatriated with Ebola that any attention was paid.

One argument made when Tedros was running for election as the WHO’s director-general was that his country of birth and experience as a foreign minister would help him cut through some of these political issues. And, indeed, one of Tedros’s major early successes was the Ebola response.

All this means that it is deeply unhelpful to try to adjudicate on the quality of the WHO’s response while this epidemic is still gathering steam. The judgements will come later, and my feeling is that they will be positive.

Even as Trump was suspending WHO funding pending review, the crisis in his own country’s testing capacity was pushing the story into the background. No one should wish any more suffering on the American people. Case numbers there will soon approach the million mark, notwithstanding the test shortfalls. With no evidence that fatality rates are lower in the United States than elsewhere — if anything the opposite — the number of deaths will inevitably pass the 100,000 mark. Care, treatment and vaccines are desperately needed.

This is the real issue. Forget the rest. •

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Like many who returned from the war, she never talked much about her experiences — just an occasional remark, mostly about lighter moments, never about the terrible ones. What stuck in her mind about El Alamein, I recall her saying, was how loud the sound of the artillery had been through the night, and how long it lasted. She would never hear a word spoken against the Salvation Army, who were as close as possible to the front line offering cups of tea and comfort.

The second battle of El Alamein — exactly halfway through the six years of war, as it happens — was pivotal. The Allies never won a battle before it, Winston Churchill wrote, and never lost one after. It was the prompt for the British PM’s famous November 1942 speech, which included the lines “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

New York’s governor, Andrew Cuomo, quoted those words last week as the rate of the rise in deaths from Covid-19 started to decline in his state. But I am not sure we have yet fully grasped what they really mean when they’re applied to these figures. The risk is that the “curve” starts heading down and wishful thinkers start declaring victory. As Churchill also said in that famous speech, “I have never promised anything but blood, tears, toil and sweat,” and there is a lot more of that to come before we see off Covid-19.

Perhaps the clearest picture yet of what it will take to control the rebound after the first wave of infection subsides comes in a paper published by the Lancet this week. Kathy Leung and colleagues from the University of Hong Kong look in detail at provinces outside Hubei in mainland China. As others have done, they point to the importance of keeping the reproduction rate below one (R_t<1 in their terminology), but they also highlight that any return to a rate above one would ratchet up the baseline number of infections in the community. This means that “simply tightening control interventions again to maintain R_t=1 would not reduce the burden back to its original baseline”; to do that would involve extra effort:

Therefore, relaxation of interventions to allow R_t>1 would probably incur both marginally higher health and economic loss, even if the disease prevalence could subsequently be pushed back to pre-relaxation level. Thus, proactively striking a balance between resuming economic activities and keeping R_t below 1 is likely to be the optimal strategy until effective vaccines become widely available.

Singapore is perhaps the clearest signal for Australia. It established the gold standard for successful initial responses to the virus but has now gone into a more aggressive “circuit-breaker” period of lockdown, including school closures, in response to new local clusters of infection, even as cases coming from overseas have reduced to zero. The first of the resurgent cases were found in foreign-worker dormitories, but here also Singapore has established a gold standard, with prime minister Lee Hsien Loong’s promise to pay “close attention to the welfare of the foreign workers.”

On Friday, Lee reminded Singaporeans that these workers “came to Singapore to work hard for a living, and provide for their families back home.” They have played an important part building Singapore’s high-rise flats, Changi Airport, and mass-transit lines, he said. “We have worked with their employers to make sure they will be paid their salaries, and can remit money home. We will provide them with the medical care and treatment that they need.”

Kathy Leung and her colleagues propose that one way of maintaining the vigilance needed to manage rebound would be to develop “digital proxies for social mixing and human mobility” using the ubiquitous smartphone data collected on apps like WeChat and Alipay (no one in China uses cash any more). To assess your likelihood of harbouring the virus, they would build on the system already developed to regulate public movement in China during the epidemic according to the green, yellow or red code your phone produces.

But before you say “that’d only work in authoritarian societies like China” consider this: Apple and Google are collaborating on uses of bluetooth low-energy transmission data (the signals exchanged between phones in near proximity) to enable Covid-19 contact tracing; and Facebook’s Data for Good initiative has developed co-location maps to reveal the probability that people in one area will come in contact with people in another, as well as “movement range trends” showing whether people are staying near home or visiting many parts of town.

The alternative to big data surveillance in epidemic control is grassroots, movement-based organising, which can develop local solidarity and manage prevention and transmission as well as response. To date, other than symbolic gestures of applause or sharing of cute memes, there has been little sign of systematic movement-building. When central authorities spend much of their messaging capital on reinforcing heavy-handed policing, they undermine the notion that communities working together can find appropriate solutions. Perhaps now is the time to flick the switch to solidarity.

The lasting alternative to these non-pharmaceutical interventions will only come from an effective vaccine. The good news is that, as of 8 April, 115 candidate vaccines against SARS-CoV-2 were in the works. The bad news is that a survey of the vaccine field from 1998 to 2009 showed that even once candidate vaccines get to the pre-clinical development phase they take an average of nearly eleven years to reach market, and only 6 per cent make it through the journey. Can things be different this time? The head of the Gavi vaccine alliance, Seth Berkley, has called for a “Manhattan project” to develop a SARS-CoV-2 vaccine, involving “extraordinary sharing of information and resources.” A race to see which vaccine candidates perform best is fine for the initial stages, but then a process is needed to pick the best and take it to scale.

Warnings have already been made about fairness. Unlike the 2009 H1N1 flu pandemic, when “rich countries negotiated large advance orders for the vaccine, crowding out poor countries,” governments will need to establish a globally equitable allocation system.

This is perhaps the biggest challenge. In his Easter Sunday Urbi et Orbi message, Pope Francis firmly sided with global solidarity and against self-centredness. He may have had in his sights the US president, who exemplified all that is wrong in a competitive race to protection with his boast that he had talked with “genius” pharmaceutical companies to rush the latest experimental treatments to Boris Johnson in intensive care. The offer was politely refused, and when the British prime minister emerged from hospital he thanked the National Health Service for saving his life. There could hardly be a starker contrast between billionaire boasts of special access and an endorsement of a health service that holds equitable access at the centre of its values, even (or especially) when it is under tremendous strain.

One of the most convincing voices to have emerged in recent weeks on the theme of global solidarity is Spain’s newly minted foreign minister, Arancha González Laya. Commenting on Europe’s north–south split over mutual financial support, she singled out the trenchant Dutch opposition to assisting countries like hers. “We are all in the same European boat” that has run into an iceberg, she said, and all of us are facing the same risks, whether or not we are in first-class berths.

Famously, survival rates from the Titanic demonstrate that first-class passengers did indeed have a better chance of making it out alive (although gender and age had an even larger impact — it was a case of “women and children first”). Those whose chances were the poorest were the crew — perhaps most analogous to the doctors, nurses, cleaners and orderlies staffing health facilities on the front line of this pandemic.

It has often been said that AIDS was an “equal opportunity disease.” Like Covid-19, wealth and education have been no barrier to infection. In that sense we are all in the same boat. But once the boat is sinking, your chances are indeed strongly affected by class, hence the spectre in the United States of much higher Covid-19 death rates among African-American populations.

These inequities won’t fix themselves, but they can be fixed, and we ought to take heart from the chorus around the world demanding it.

Perhaps the neoliberal era will end with both a crash and a whimper. •

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A librarian and historian, Matt was the family history sleuth for my recent collection of memoir essays, and his grasp of our family’s story is much more detailed than mine. I was aware that my mother’s young sister had died as a child but not that she had been struck down at the age of three by the devastating flu that killed at least twenty-five million people, and possibly as many as one hundred million, just after the first world war. My middle name is Joyce, after the aunt I never knew.

Going back through the transcripts of the tapes Matt recorded with his grandmother in the 1990s, I found a comment she had made about her childhood in Watford, near London: “After the war we had a terrible flu epidemic and we all got it, but with Joycey it turned to pneumonia and she never really recovered from it.” The delicate little girl started school but had to give up through illness; she was then nursed at home by her mother until she succumbed to heart failure in 1924, just after her eighth birthday.

The influence of chance on the trajectory of our lives has always fascinated me — how planned paths swerve as a result of an unexpected personal event, or how wars, or indeed pandemics, turn those plans upside down. Thirteen when her sister died, my mother was attending a secondary school that provided early teacher training and was planning to complete the qualification at a college in London. She knew the direction her life was to take. Or so she thought. In fact, having immersed myself in our family archive, delved into Trove and consulted with Matt, I have come to see that the effects of my young aunt’s death from Spanish flu rippled so widely that my very existence can be traced back to it.

My mother, Rose Wythe, lived with her parents and little sister in a comfortable rented house in Watford, its front covered in a Virginia creeper that became “just one big splash of red” in autumn. My grandfather ferried around travellers by horse and trap as a coachman for Kinghams, a large grocery store that smoked its own bacon and hams. My grandmother was the homemaker. My mother loved her school life and the company of her girlfriends there. She was a born teacher, and I feel sure she would have helped Joycey with lessons when her sister was well enough. (She taught me to read at three before being called back to teaching after the second world war.)

Joyce Wythe was buried at Watford cemetery on 23 June 1924, and her grave is watched over by a stone child angel. After the funeral, the house with the Virginia creeper fell silent. Like her father, my mother continued to come home for lunch, but “sometimes there was lunch ready and sometimes there wasn’t. It was a very sad time.”

My mother’s two older brothers had found it hard to enter the workforce after the war ended in 1918. “Lewis was apprenticed to engineering and after the war the soldiers who did come home got their old jobs back,” my mother told Matt. “So that was the end of his apprenticeship. And it was very hard to get anything else. Wilfred was younger — he was very clever artistically and he really wanted to be an architect, but that was wiped on the head too.”

Seeking more opportunities, the two young men had set off to Australia in the first wave of postwar emigration. After Joycey died, Lewis implored his parents to join him and Wilfred and, in their unhappy state, my grandparents eventually agreed to set sail for the other side of the world. My grandmother seems to have regretted the decision for the rest of her life; and my mother, of course, was devastated. “I suppose these days,” she told Matt, “I would have stood out and said I was going to stay behind, even if I got a job to help me. But you did what your parents said then.” At fifteen, she really had no choice.

Before the family set sail in early 1926, my mother spent as much time as she could with her friends, staying the last night at the home of her best friend, Doris. She made sure that two small autograph books I hold in my hands today were packed in her trunk as precious mementos of the life she was to leave behind. They consist mostly of sentimental verses about friendship or extracts from poems by Tennyson, Kipling and others, all written in carefully formed cursive script and signed by friends or teachers.

Interspersed are pen and ink drawings and watercolours, including drawings by one of my mother’s cousins, a teenage boy at the time, from Aldeburgh in Suffolk. Dated August 1921, they show that he was fascinated by the machines of war — airships, warplanes and steamships — that he had grown up with. Watercolours of flowers by my mother’s friend Doris stand out for their artistry. The two women were still corresponding seventy years later.

A farewell watercolour by Rose’s friend Doris.

The voyage on the P&O steamer SS Barrabool, bound for Adelaide, Melbourne and Sydney with more than 1000 emigrants on board, was more eventful than any of the passengers could have imagined. My grandmother, a “bad traveller,” was seasick for most of the journey and confined to her cabin. So she wasn’t among the passengers who stood on deck for hours — in the middle of the Atlantic Ocean, en route to Cape Town — watching a lifeboat ferrying people from a burning cargo ship, the Parapoa, which carried sixty-nine crew and five passengers. All were rescued safely, including six stowaways and a pedigreed fox terrier. An open crate of pigeons remained on the ship, left to fly away if they could. Those rescued were disembarked at Cape Town, and that was where, according to my mother’s memory, passengers with smallpox were unwittingly taken on board. Five people would die over the next weeks.

Newspaper accounts of the outbreak on the Barrabool vary, but the one in the Adelaide Advertiser of 12 April 1926, which describes the scene after the ship docked at Semaphore, resonates uncannily with accounts of Covid-19 on cruise ships docking in Australian waters in 2020:

The vessel was boarded by Drs. C. Wiburd and P.T.S. Cherry, who were handed the primary health report, which stated that no sickness had occurred on board, with the exception of a series of cases of measles among children. However, as Dr. Wiburd was leaving the ship’s hospital, he noticed two male passengers on the deck with a rash on their faces which indicated smallpox. One of the men seemed to have had only a mild attack of the disease. Both sufferers, who had been in a febrile condition, were mingling among other passengers on the deck… Drs. Cherry and Wiburd, in the course of the examination of the other passengers, found another man whose face, hands and feet were covered with the scars of smallpox. He had taken ill shortly after the vessel had sailed from Las Palmas, and after being detained in the ship’s hospital for some days, was discharged.

The passengers bound for Adelaide and those who were ill were taken to the quarantine station on Torrens Island, where they were disinfected, vaccinated and placed in quarantine. The remaining passengers heading to Melbourne and Sydney were vaccinated on board before the ship resumed its delayed journey. From Port Melbourne approximately 300 were taken to the Port Nepean Quarantine Station, perched on the rugged coastline at the tip of the Mornington Peninsula. Some 600 passengers then continued on to Sydney.

The Melbourne Argus announces the Barrabool’s quarantine.

Those sixteen days’ quarantine at Portsea were my family’s introduction to their new country. My mother remembered the seaside town as a beautiful place, although the station itself was very plain and the inmates slept in barracks. She would have seen the administration building, erected in 1916, with its handsome facade, but that is not where the internees were housed. In her recollection, “ships came back, I don’t know how many times, bringing the dead — the Sydney people. It was an awful beginning.”

Although that part of her story can’t be verified, an account in the Melbourne Age of 30 April 1926, two days after most of those quarantined were released, does support some of her memories:

The first case of small-pox was recorded at Las Palmas, and during the continuation of the voyage a number of the vessel’s passengers contracted the disease. During the latter part of the voyage five deaths were recorded. Two of the crew and one passenger contracted pneumonia with fatal consequences. A girl of thirteen years also died of the malady. The last death was recorded on Monday, when a child two days old died.

The quarantine station at Portsea had opened in 1852, making it one of the first in Australia. The oldest buildings on the site, which continued operating until 1980, date back to that period. It was the scene of part of the little-known history of Spanish flu in Australia, after servicemen suffering from the disease started pouring back into the country from the war in Europe in 1919. Twelve emergency timber huts were hastily erected, each holding thirty-two men, which suggests the victims numbered in their hundreds. In total, an estimated thirteen to fifteen thousand people died in Australia during the pandemic.

Because my grandfather reacted badly to the vaccination and had a severely swollen arm, my family was kept at Portsea for a week longer than most of the new settlers. As my mother recalled, “I had a pretty bad arm, but my father’s was terrible… And Mother, who had been so sick on the ship, was immune to the vaccination — it didn’t have any side-effects at all.” With Wilfred having already moved to Sydney, the travellers eventually met up with Lewis in Melbourne. Instead of finding accommodation for them in the city, he took them twenty miles away to Werribee, then a small country town. There, my grandfather found work as a stableman and labourer at the State Research Farm, where he would spend the rest of his working years.

My grandmother hated Werribee and my mother resented Lewis for the rest of her life. “He was always doing the wrong thing, that brother,” she told Matt. “I don’t owe him anything. He was such a queer bird. Funny how people can be so different in a family.” It seems that the feeling was mutual; as she remarked dryly to Matt, “He was the one who told me that if I ever knitted anything for him he wouldn’t wear it anyway. So I didn’t knit anything for him.”

In spite of these inauspicious beginnings, Werribee was to play an important role in our family history. My mother became a relief teacher a few years after she arrived, leaving the little town for extended periods to work at single-teacher schools around the state. But Werribee was where she met her future husband, who was working in his father’s cafe and playing piano in a local band. They married in Scots Church in Melbourne in 1935 and, using my father’s skills as a pastry chef, opened a cake shop in the eastern suburb of Glen Iris.

Their suburban life was short-lived. When the second world war broke out in 1939 — the second world conflict they were to live through — my father joined the airforce and my mother followed him from posting to posting with their baby son. I arrived towards the end of the war and, after my mother was recalled to teaching during the early postwar boom, I started school before I turned five.

In the light of my family research, I pondered again the question of why the Spanish flu has left such a small footprint on our collective memory and came up with some possible answers. The pandemic came on the heels of a war that ravaged the world, of course, and has thus remained hidden in its shadow. More than that, my parents’ generation lived through a century that encompassed not one but two world wars. As well as causing death and disaster, wars can create the heroes and narratives that define a nation; pandemics offer no enemy but the disease itself, and are thus harder to memorialise. People simply wish to forget them.

In a collection of essays on the history of quarantine, Anne Clarke, Ursula K. Frederick and Peter Hobbins remark on the inconsistency between historical records and stone inscriptions. They speculate that the paucity of inscriptions mentioning disease at quarantine station sites could reflect “a strategic amnesia — a way of moving forward and beyond the spectre of death.” Mentioning the SS Barrabool as an exception, they observe that the vessel is virtually missing from the historical archive (and the varying accounts I did unearth are wildly inconsistent) and yet its smallpox cases are mentioned on a number of rock inscriptions around the quarantine station at Sydney’s North Head, which was the ship’s final destination on that fateful voyage. Perhaps the discrepancy can be explained by the fact that forty of the passengers on board were stonemasons who were specially recruited in England to craft the stone foundations of the Sydney Harbour Bridge.

Uncovering small stories like my family’s can shed light on the larger narratives of wars and pandemics. Writing this, in the midst of the coronavirus, a century after my young aunt was stricken by the Spanish flu, I find a certain ironic symmetry in our stories. Joycey was a child during a pandemic that struck children in larger numbers than any other age group. This time it is the older generation that is most vulnerable and I am completely housebound, except for a daily walk with the dog, for the foreseeable future. I am one of the privileged, though, as I share my comfortable home with my partner, with my books, archives and the internet at my fingertips, and with frequent virtual access to family and friends. •

My thanks to Matthew Stephens for his assistance in the research for this essay.

The post The aunt I never knew appeared first on Inside Story.

If you answer that question wrongly, your modelling will get everything else wrong, no matter how careful you are with the details.

Unfortunately, or perhaps fortunately, the government’s expert advisers appear to be using the wrong answer, or at least they were in the modelling report released on Tuesday. That modelling, undertaken before we had experience of lockdowns, assumes that R will be greater than 1 even after we’ve locked down. This implies that the infection will keep spreading until it is limited by “herd immunity,” where so many people get infected that the growth rate has to finally slow, and R shrinks below 1.

But all the evidence, here and overseas, suggests that lockdowns push R below 1 regardless, which means the number of new cases declines over time. In the absence of a vaccine, that decline will be reversed if the lockdown is relaxed substantially, pushing R back above 1.

With smaller numbers of active cases, though, it should be possible to expand testing criteria to include all contacts of cases, whether or not they are symptomatic, and to undertake random testing, as is being done in Finland. This would provide better guidance on the stringency required for continuing controls.

The importance of R can be illustrated by the most familiar example of exponential growth, that of compound interest.

Suppose you invest $1000 and earn a 5 per cent rate of return. At the end of a year, you will have your original $1000 and a return of $50, meaning that R would equal 1.05. If you leave the interest to compound, after two years you will have $1050 plus the next year’s interest of $52.50, bringing your sum to $1102.50. And so on.

Suppose, however, that you simply put your money under the mattress. Then R would equal 1 and your $1000 wouldn’t grow.

Worse still, suppose that while your money sat under the mattress, prices were going up at an annual rate of 5 per cent. It would mean that after one year the purchasing power of your $1000 would have shrunk to $950 at the original price level. Over many years, with enough inflation, the value of your money would shrink to almost nothing.

This simple example illustrates the knife-edge property of R=1.

Of course, even with R greater than 1, exponential growth can’t go on forever without running into limits of some kind. In the case of an epidemic, the limiting factor is that, for most diseases, people who have been exposed and recovered acquire partial or complete immunity.

As this happens, R falls.

Suppose, for example, that each infected person passes the virus on to two others. R would equal 2. After a time, though, when half the population has been exposed, each infected person can only generate an average of one new infection, meaning R equals 1. After that, the infection rate will decline to below 1.

This “flattening the curve” graph released by the government illustrates the point. The uncontrolled case corresponds to R=2.53, estimated on the basis of the early stages of the Wuhan outbreak.

Social distancing (including lockdowns) is assumed to reduce R to between 1.69 and 1.9. Quarantine and isolation have a slightly more complex effect. The end result in the government’s publication is that, whatever measures are adopted, R stays above 1.

Source: Australian Government, Impact of Covid-19

What these assumptions mean is that the best thing we can hope for is to slow the spread enough for the hospital system to cope.

This is a gloomy picture, but it is important to recognise that modelling is an ongoing process and the official position is evolving. The research this week is based on early experience in Wuhan and does not incorporate evidence on the results of lockdown measures here or in other countries. So far, the decline in new infections suggests that stringent lockdowns are sufficient to push R well below 1 after only a few weeks.

Everywhere a sufficiently tight lockdown has been imposed, the number of new cases has peaked and declined long before herd immunity became relevant.

China used the most drastic measures and has reduced new cases to a trickle. South Korea (where statistics are more reliable) has done the same with more moderate restrictions. Even in European countries like Italy and Spain where the pandemic got out of hand before the controls were imposed, new cases have begun to decline.

For the moment, any problems with the government’s modelling don’t matter much. Whatever the value of R, it makes sense to maintain the existing lockdown measures for now.

But an assumption that R will stay above 1 might lead to ill-judged choices in the future, allowing a steady spread of the virus.

As New Zealand has made clear, our objective ought to be eradication. So long as R is less than 1, and extensive testing is used to control any outbreaks (locations or occupations in which R is greater than 1), there is no reason to think this is impossible. •

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This week, the US Centers for Disease Control and Prevention joined in, endorsing the use of masks by the general public. A flurry of articles have struggled to filter the evidence for and against. Some commentators are even saying the evidence now shows that SARS-CoV-2 is capable of not just droplet transmission but airborne transmission too. So, what can we make of all this? Here are three key things you need to know before you pull on that mask.

HOW COVID-19 IS TRANSMITTED

The virus that causes Covid-19 is known as SARS-CoV-2. Initially of animal origin, it aroused global health concern when reports of human-to-human transmission emerged in December 2019. After it began spreading in Wuhan, the city was locked down and 1800 teams of five or more epidemiologists descended, tracing all cases and their contacts. That research provided a detailed picture of what happens before control measures are put in place, and it found that the average person who contracted Covid-19 transmitted the virus to 2.2 other people over the duration of their illness. Importantly, they were almost always people with whom they had close and prolonged contact.

Some people have interpreted the recommendation that we keep at least 1.5 metres from each other as meaning the virus is easily passed on via brief and casual contact. The contact tracing carried out in Wuhan gives a better picture of how this condition really is transmitted.

When we say a viral pathogen is capable of airborne transmission, we mean two things at once. One is that people who are sick cough up particles of five microns or less, which are typically generated deep in the lungs and can hang in the air for hours after a cough or sneeze. The other is that inhaling those particles is enough to cause a new infection.

You can catch measles, for example, by walking into a room that somebody with measles coughed in hours earlier — you don’t need to have direct contact with that person. This is why measles spreads like wildfire in unvaccinated populations, as we saw recently in the tragic outbreak in Samoa.

The spread of SARS-CoV-2 beyond its epicentre in Hubei coincided with Chinese New Year, when people from all over China travel for hours at close quarters on planes and trains back to their home towns. If Covid-19 were airborne, that would have been clearly visible in the epidemiology of the outbreak.

Epidemiologists in China were almost always able to identify whom each person had caught Covid-19 from, because the two people had spent time in close physical proximity, where droplets from coughs and sneezes can be transferred from surfaces, via hands, onto faces.

If the condition were airborne, there would have been many cases of transmission — of genetically linked virus — where the people involved were never in the same room at the same time. With upwards of 80,000 cases in China, we have a high degree of confidence that Covid-19, rather than being airborne, is passed on via droplet transmission.

Some mask proponents cite a study that found SARS-CoV-2 particles in “air-conditioning ducts” as evidence of airborne transmission. The ducts in question turned out to be the extractor vent for a negative pressure isolation room occupied by a symptomatic patient at an outbreak centre in Singapore. The same study used sensitive methods to test for virus in the air itself — and all of those tests came back negative.

Mask advocates also cite a recently published study that found genetic material from viruses that cause influenza and head colds in exhaled breath. Other studies have reported droplets from sneezes travelling up to eight metres from the sneeze that produced them.

These studies don’t answer a key question: were there enough droplets after eight metres; did they have enough virus in them; and was the virus infectious enough to infect another person in the absence of close and sustained contact?

The answer depends on the illness and even varies according to the strain of the virus within broader viral families. In this outbreak, we have no evidence to believe that SARS-CoV-2 is capable of airborne transmission.

Rather, Covid-19 is passed on when coughs and sneezes spray droplets of mucus and spittle onto nearby surfaces. When we touch those surfaces, we may transfer them to our face, allowing the virus to establish infection. This is why we recommend handwashing, avoiding facial touching, coughing or sneezing into your elbow, and keeping a physical separation from others.

WHAT (AND WHO) MASKS ARE GOOD FOR

Mask advocates are correct in picking up an apparent contradiction: why are masks protective for healthcare workers but not for the general public?

It comes down to social distancing. Doctors and nurses can’t listen to your chest from 1.5 metres away — they have to get right up in your grill, within the blast radius for coughs and sneezes. Guidelines in Australia recommend a surgical mask for face-to-face treatment of patients with confirmed or suspected Covid-19 illness. There’s an additional subset of treatments, known as aerosol-generating procedures, which call for an N95 respirator. This includes lifesaving interventions like intubation. So it’s vital we preserve clinical wear for clinical care.

Clinicians get no benefit from using higher-grade personal protective equipment, or PPE, than recommended. Anyone who is unfamiliar with this equipment runs the risk of accidental self-contamination when taking it off, as we saw during the Ebola crisis.

Surgical masks are also given to clinic and hospital patients who have respiratory symptoms, or who are confirmed or suspected cases of Covid-19. This is known as source control, with masks protecting others by catching droplets from coughs and sneezes. This is essential when people with symptoms seek out medical care. Other than that, if you have symptoms, or a recent close contact with a known or suspected case, you should not be out in public at all — mask or no mask, you should be at home in self-isolation.

If you’re not in either of those categories — a healthcare worker getting up close and clinical, or a person seeking testing or medical care — is there any benefit in using a mask? The potential benefit depends on how much risk you would be facing without the mask.

The Communicable Diseases Network Australia defines two conditions where the risk of Covid-19 transmission is greatest: close and sustained personal contact. Close contact means face-to-face for fifteen minutes or more; sustained contact means sharing a closed space for a prolonged period (two hours plus).

Brushing past someone in a supermarket aisle is unpleasant at a time when our anxiety levels are heightened, but it’s not a significant risk. The benefit is much greater for clinical workers who have close and sustained contact with known and suspected cases of Covid-19, so we should prioritise their access to clinical masks.

Some people want to wear masks when they can’t avoid getting close to others, for example if they are waiting in a long queue for Centrelink or have no choice but to catch public transport to work. Many of us are already going outside as little as we possibly can, and we want to do everything we can to protect ourselves and others when we do venture out.

That’s completely understandable. Keeping our physical distance from others whenever we can, keeping our hands clean, and minimising touching our faces and common surfaces remain the most effective things we can do to protect ourselves and other people when we’re out and about. To protect others, we should not be going out at all if we have any cold or flu-like symptoms, unless we are headed straight to the doctor’s office. And if wearing a face covering would make you feel safer, the next section offers you some options.

IF YOU REALLY WANT A FACE COVERING

We have already begun to see people on Twitter seeking to shame or stigmatise anyone who goes out in public without wearing a mask. This is a concerning development. Stigma is a powerful regulatory force — anyone can pick it up and use it to shape someone else’s behaviour. But once stigma is unleashed, once we reinforce social norms with blame and shame, it can’t be undone, even when it produces unintended consequences. We need to ensure that our use of face coverings does not put healthcare workers at risk of infection and death with Covid-19.

There is a major shortage of PPE, which includes the surgical masks and N95 respirators used by healthcare workers to treat patients without contracting the virus themselves. A petition with over 152,000 signatures calls for transparency about the Australian PPE stockpile, with some healthcare staff quitting over the lack of protective equipment.

In some countries up to 10 per cent of Covid-19 deaths have been healthcare workers. If you want to wear a mask, your first thought should be avoiding contributing to the dire situation facing doctors, nurses and paramedics — not least because they deserve our care, but also because you, or your loved ones, may still end up needing their help. None of us should be using medical masks that might be needed by health professionals who are trying to save our lives.

The first step is not to buy masks for yourself. You might think, “Oh, two or three won’t hurt,” but you’re creating a demand that will divert stocks from where they’re needed. We’ve just seen what happens when everybody buys “a little bit extra” pasta and toilet paper. If you already have a mask you bought during the bushfire crisis, go right ahead. You could also follow instructions to make your own face coverings, which were written for healthcare workers who can’t obtain the real thing. Studies have shown these coverings are less effective than manufactured masks for healthcare workers, but this may be offset by the much lower risk you are facing in everyday life.

Second, there’s important information embedded in those DIY instructions. They tell us to make plenty, as masks quickly become saturated with moisture from breathing and need to be replaced regularly. If you have Covid-19, a damp mask is full of viral particles ready for droplet transmission. Touching these contaminated masks and then touching surfaces is dangerous to other people. Used masks should be plastic bagged and go straight in a hot wash overnight.

Third, if you are wearing a mask to protect yourself, you must teach yourself not to adjust the mask with your fingers — that’s facial touching, and it will put you at risk. Droplet transfer is still the biggest risk for infection by far, and masks can increase that risk. Learn how to put facial coverings on and take them off so you don’t end up brushing their exterior surfaces with your fingers, or against your face — even healthcare workers find this a challenge. Always wash your hands before and afterwards, and don’t relax about physical separation.

Wearing a face covering can be a potent signal that you are doing your bit to curb the epidemic. But if we all begin buying and wearing clinical masks in public, that symbolic gesture will pose a very concrete risk to healthcare workers’ lives. Making your own face covering lets you signal your care about your own health, the safety of our doctors and nurses, and ending the outbreak. If you want to cover your face, this is a very personal, concrete and practical approach. And even the US surgeon-general is getting in on the act. •

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Libertarian think tanks and law and economics professors expressed concern that the cure might have been worse than the illness. (This, of course, is a position you can only hold if the cure actually works.)

From all quarters came calls for caution against complacency. Some commentators who had courted panic by interpreting the initial slope of the curve as evidence of exponential local transmission now scrambled to point out that the slowing reflects the drop-off in overseas visitors, with local transmissions continuing their trend of gradual increase. Advocates of an elimination strategy argued that now is the time for lockdown, scenting the prospect of completely eradicating local transmission.

As the pace of new diagnoses begins to slow, at least for the moment, it seems a good time to reflect on the mid-to-long term. What would an endgame look like?

We have had an intense debate over what broad approach we are taking — flattening or bending the curve, or complete eradication. In practice, the methods are the same; the difference is a matter of timing and emphasis. But debate still rages over a false dichotomy expressed in loaded terms: after all, who wants to advocate a policy widely described as mitigation?

Yet “flattening” includes preventing cases, not just spacing them out so that hospitals can cope, while “eradication” anticipates that the epidemic would rebound if restrictions were eased too early or lifted altogether.

Nobody at the centre of Australia’s response to the epidemic believes we are going to see results from a “short, sharp shutdown,” as advocated by some vocal commentators. At state and federal levels, chief health and medical advisers say restrictions must remain in place for months and may intensify.

In the discipline of change management, there’s a saying, attributed to Peter Drucker, that “culture eats strategy for breakfast.” Simple and decisive strategies like lockdown can easily founder on the shoals of implementation. The PM has fairly been criticised for making a hash of communicating the government’s piecemeal introduction of recommendations and restrictions. But that graduated introduction, with heavy foreshadowing of tighter restrictions to come, has given the public time to prepare, mentally and practically, for a curtailment of everyday life that is likely to be a marathon rather than a sprint.

The big question is what happens when restrictions are lifted: does the epidemic rebound? This is where notions of flattening or bending the curve fall short. The most well-known alternative is a model developed by Neil Ferguson and popularised by startup founder Tomas Pueyo that explicitly anticipates rebound. Pueyo called its two moves “the hammer” — an initial, immediate, short, sharp lockdown — and “the dance” — monitoring the epidemic and pulsing restrictions on and off, as needed, to curb the epidemic’s growth.

What this fantasy born of simulation overlooks is that policy involves people. Trying to plan ahead without any certainty about whether and when restrictions will be reimposed will become extremely burdensome. As the public tires of the dance, adherence will decrease, and it will lose effectiveness. Of course, this problem applies equally to all restrictions.

It all comes down to rebound. If Australia succeeds in bending the curve, does the rate of new infections simply return to unacceptable levels when restrictions are lifted?

We can easily imagine rebound happening if travel bans are lifted while the pandemic rages unchecked beyond our borders. Within our borders, though, Australia relies on precarious migrant labour — people whose lack of social security means they have to work in order to survive, even if they have mild respiratory symptoms. Low-level ongoing transmission among workers exempted from stay-home measures, be they permanent residents or otherwise, could allow rebound even without any easing of overseas travel bans.

We are watching carefully for rebound in countries that have controlled their initial outbreaks using the same approach as our own — intensive social distancing, aggressive contact tracing, and isolation of known and suspected cases. Both China and Singapore, exemplars of this approach, have reported mild increases in cases involving local transmission. Singapore this week opted to introduce more intensive social distancing measures involving shutdowns.

Epidemics are complex and unpredictable, and a cluster or super-spreader event could change the behaviour of our outbreak altogether.

We don’t know if or when a vaccine will become available. Until that happens, we are facing prolonged restrictions and ongoing uncertainty about the endgame. Our approach needs to respond to our own epidemic, our own population and our own health service capacities. It will not slot neatly into some conceptual debate, nor should we expect it ever would. •

BONUS READING

This article includes some text from a new resource by the author outlining the evidence and experience underlying Australia’s recommendations for preventing transmission and curbing the outbreak. It’s available free here.

The post Reflecting on the endgame appeared first on Inside Story.

For some, this closing of borders is a sign that globalisation was all a big mistake — that Covid-19 proves we should retreat into smaller and smaller communities. Others see travel restrictions merely as a pragmatic way of slowing viral spread, and point to flourishing global solidarity in shared experiences of quarantine.

The debate is an old one. Human geographer Yi-Fu Tuan is just one theorist who has pointed to divergent attractions of the hearth — with all it implies in terms of closed, monocultural societies — and the cosmopolitanism that must make rules to accommodate difference within shared social space.

Ilona Kickbusch, director of the global health program at the Graduate Institute in Geneva, has suggested that a “cosmopolitan moment” occurred when the experience of SARS cemented a global commitment to the International Health Regulations: “Cosmopolitan moments are points in time at which the global community comes together and creates new institutions and mechanisms that it has not otherwise been willing to introduce.” Covid-19, she writes, is just such a moment, teaching us “that international solidarity is an essential response and a superior approach to isolationism.”

Despite the recognition of Covid-19’s spread to nearly every territory on Earth, national differences in epidemic curves, infection rates and death rates have been eagerly seized on. Those comparisons have been used partly to calibrate the intensity of a country’s own responses, especially when it comes to restrictions of movement. Naturally, the success or otherwise of epidemic containment strategies and their associated models has been eagerly pored over. (Perhaps too eagerly in some cases — thirty-six hours after the head of the Imperial College modelling team, Neil Ferguson, attended 10 Downing Street in mid March he came down with the telltale Covid-19 symptoms and tested positive. He has since recovered.)

But some of the differences don’t yet have a good explanation. Why are Germany’s death rates a tenth of those in Italy, for example? Will the disparity be sustained? Are they real differences in clinical progress, or just a marker of different stages in the epidemic and different denominators of the size of the infected population? As the former Chinese premier Zhou Enlai might remark, “Too early to say.”

Chance cannot be discounted as the underlying reason for these differences. For nearly two decades, it was a mystery why HIV rates in the Philippines and Japan had remained so low, even in the most likely populations, such as gay men. All the risk factors looked similar to comparable countries in the region and across the world. Then, in the early 2000s, HIV rates suddenly took off in both countries, and the response that had been on hold for years had suddenly to be ramped up.

Epidemics are subject to the dynamics of population mixing patterns, environmental and other conditions, and purely chance infection events. Even subtle differences can have major impacts, so it is important not to over-interpret models or emerging empirical evidence.

It is even possible that the origin story of SARS-CoV-2 will change, and that ground zero may not be a wet market in Wuhan. There have been intriguing signs of clusters of unexplained severe pneumonias in northern Italy as far back as October 2019, and epidemiological detective work is being undertaken by the University of Milan’s Professor Adriano Decarli. Chinese media have amplified the theory that the virus originated in Italy and was transported to Wuhan — the vector in either direction being the trading links between the two regions, eerily reminiscent of the plague’s progress along the old Silk Road.

The Silk Road also features in a heated debate in international relations circles between those who welcome China’s post-Wuhan assistance to a world in need via a “health silk road,” and those who decry this as propagandising. As Chinese writer Wang Xiuying wryly reflected back in February from lockdown in Wuhan, “In the West, panda-huggers say no other government would be doing better [than China’s] under the circumstances; dragon-slayers are cheerleading for the end of communist rule, as they do every time there is trouble in China. Whatever happens, those arguments won’t change.”

The brute force of the epidemic will shape those debates, nowhere more so than in the United States, where the limitations of market-based healthcare are being laid bare. Healthcare interest groups, trained to maximise their profits, are behaving badly amid rampant profiteering and the hoarding of intellectual property. System infrastructure shows many signs of fracture.

Something clearly went wrong with the high-profile global health security index, released last year, which ranked the United States as the country best prepared for a pandemic, and Britain second. (Australia was in fourth place.)

Some countries, meanwhile, have surprised in the strength and quality of their response. Given South Africa’s tardy and conflicted response to HIV, which left it with the world’s biggest epidemic, it may have been expected to struggle with the added challenge of Covid-19. But perhaps the long challenge of HIV led to all the necessary learnings. In my view, South Africa’s Covid-19 health portal is the best in the world: the number of tests, positives, recoveries and deaths are displayed in a daily ticker, and links provide clear and coherent video guides for all audiences. President Cyril Ramaphosa has provided clear and calming leadership, initiating a three-week nationwide lockdown from 26 March. Health minister Dr Zweli Mkhize has run the day-to-day response, which includes mobile testing units.

That is not to say challenges won’t arise. Many South Africans have very few resources on hand to tide them over, even for the briefest periods. Over the border in Zimbabwe, which has been struggling with a comatose economy, the situation is worse. A few days ago I was forwarded a WhatsApp message from a single mother in one of the poorer suburbs of Harare who had been warned, and was able, to stock up on goods before the nationwide lockdown came into force: after three days, she said, her neighbours are crying out of hunger. When water comes from a communal pump, the practicality of physical distancing also comes into question.

It’s easy to become obsessed by the unfolding epidemiology of a pandemic. But the epidemiology is only one small part of a picture, and is mainly useful to predict what case numbers are coming down the track. The much bigger part of the picture is the response itself: the changing of behaviour to minimise cases and the treatment given to those who fall ill.

The US National Institutes of Health’s global database of clinical trials today lists 306 registered clinical trials for Covid-19 treatments. Some potential treatments have received global attention, others not. But expect over the coming weeks dozens and dozens of stories of promising compounds that kill SARS-CoV-2 in the test tube, almost all of which will eventually fall by the wayside.

The clinical techniques for managing those made most ill by Covid-19 are advancing rapidly. But the unprecedented flood of medical writing, published in record time, brings its own problems, with good peer reviewing in short supply. Some results are counterintuitive. I was surprised by an analysis that showed asthma sufferers to be under-represented in cases diagnosed with Covid-19: reasons are not yet clear, but it should give some comfort to those who have been worried that they were at higher risk, even as more definitive answers are sought.

Systematic research on the behaviours that sustain good Covid-19 responses still seems to be lagging. The COSMO initiative, which comes out of the World Health Organization’s Europe office, is a welcome exception. It provides a standard protocol and platform to collect data on knowledge, risk perceptions, preventive behaviours, and public trust during the current coronavirus outbreak. Already, national data collections are under way in Germany, Denmark and Argentina.

The stern policing that seems to undergird the current phase of the Australian Covid-19 response is not the same as the lasting response that will be needed until Covid-19 fades into the background. And that response will depend on the public’s willingness to police itself by communally developing new social norms based on good health literacy. We can be cosmopolitans and devise the new rules to live with one another, because the alternative is solitary, poor, brutish and short. •

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It’s only got weirder since then, of course, and the walls at home are closing in fast. The dog’s loving it though. Walks are longer and more frequent; he’s got plenty of friends down at the park and social distancing doesn’t appear to be a huge concern for any of them. My son’s loving it too. Nothing focuses a fifteen-year-old boy on what’s important like a school lockout. For him it’s the perfect crime with zero downside: arson minus the fire and the risk. My daughter? Bored. That’s not all that remarkable — she’s twelve and it’s a common refrain among her cohort. She’s been going okay though, hanging out in the kitchen with a friend of hers she’s known since prep. His kitchen’s in San Francisco. He’s bored too.

Given the more pressing problems around, boredom doesn’t qualify as a problem at all. Virus or no virus, it never really has. I don’t know who said it but we’ll struggle for a decent novelist in the future if no one ever gets bored and stares out a window. Perhaps, and if we do what’s being asked of us and stay indoors, we can look forward to some good art coming out of Covid-19. If the artists survive it, that is, which they surely will. If the arts community is familiar with anything it’s the bones of its collective arse. If you need proof of that, try googling “ministry for the arts in Australia.” You’ll end up deep in the Department of Infrastructure, Transport, Regional Development and Communications. There’s an office in there somewhere with Arts on the door. Maybe.

While it’s not only the arts that have been devastated, no other trade has been shut down so swiftly and unceremoniously. Sport dragged its heels in a protracted farce, Crown Casino likewise. Restaurants are hanging by a thread and the best a waiter can hope for is a gig as a delivery driver. But the arts? A couple of weeks ago now a friend who manages a band sent me a text: “Tonight’s our last show for quite a while… last coin for a while too.” This after a period that saw a multitude of benefit gigs across the country for bushfire victims and their communities. Those with shallow pockets have always dug the deepest. No surprises there.

A while ago now, in the interests of mental health and a desire for clear air on matters of public importance, I ditched Facebook. It was a good decision, for me at least. Friends may disagree, though, because now I send rants directly, via text.

Like most, I have an assortment of contacts in my phone: friends, acquaintances, immediate and extended family, work colleagues, professional connections and any number of less intimates. There’s a plumber, a couple of builders and a mechanic, musos, politicos, thespians, academics, workaholics, alcoholics, new-age hippies, office workers, business owners, people I don’t like much, people who don’t like me much, names I don’t recognise. You get the picture. Left, right and all that’s in between.

In equal parts inspiration and irritation, I texted a request for responses to a simple prompt in relation to Covid-19: “I find it curious/amusing that…” The replies came quickly, and the willingness of people to share then, and in the days following, made me regret I’d boxed them in with a such a narrow request and left deeper questions unasked. There isn’t much that’s amusing about Covid-19 after all. Some of them texted just to tell me that.

The general tenor of the responses suggests that Scott Morrison’s been presented with an opportunity to redeem himself after a summer that left many wondering if he was up to the job. For the most part, it has to be said, they’re still wondering. For many, that the prime minister has been only too keen to surround himself with experts in relation to the public health crisis is at stark odds with his inclination to distance himself from people who know a lot about the environmental one. Morrison was also criticised for his “It’s ridiculous, it’s un-Australian and it must stop” rebuke to panic buying: “I find it curious,” texted someone, “that the PM finds it necessary to chastise ‘quiet’ Australians for being rampant market-driven capitalists for buying and selling toilet paper.”

Market-driven capitalism, neoliberalism, whatever you want to call it, came in for sharp critique. As one (now jobless) texter noted, “We have to look long and hard at a system that folds in on itself so spectacularly that it can barely sustain society beyond the loss of a single weekly pay cheque.” The challenge now is that it’s far more monumental than a single pay cheque.

Those in the privileged position of having a job — for now anyway — wonder what type of workplace they’ll be returning to once the virus subsides. At the very least, employers will have a picture of who among their staff works best autonomously, who needs the social setting of an office, and who’s best left at home, free of the nine-to-five factory settings that society mostly just endures because they’re too hard to change.

Massive change, of course, has also hit the education sector. While online education has hung like a Damoclean sword over more traditional forms of teaching and learning for a couple of decades, despite the zeal of its many champions it’s a tough sell, not necessarily because of what it is as much as because of what it isn’t. Anyone who’s been conducting social and work interactions full-time for the past couple of weeks via Zoom, Skype or Facetime will appreciate what is lost. At universities at least, and particularly in arts faculties where a contest of ideas is vital to the pursuit of knowledge and shifting truths, the mooted demise of face-to-face teaching is lamentable. No matter how good sound and video quality is, the virtual classroom is no substitute for being in a room together, in each other’s company, where subtlety, nuance and body language contribute so much to modify behaviour and maintain civility.

Among tales that arrived in my phone of being swept up, or not, in panic-buying melees, there was concern about the rush on egg-laying chooks in the scramble for self-sufficiency. In the not-so-olden days, the minute a chicken stopped producing eggs at a reasonable tempo it ended up in a casserole dish. Stories of headless, bloody chickens chucking laps of the Hills hoist in the backyards of yesteryear are rife among the over-fifties and pretty much all of them involve impossible-to-shift memories of mum and dad tag teaming in the domestic slaughter. Now, your best laying hen’s called Molly or Fluffy and you have adorable photographs of your three-year-old daughter and five-year-old son cuddling her in the backyard. Even if by some miracle you manage to get the idea of Molly’s beheading past the kids, you probably don’t even own a tomahawk, much less the skill or conviction to use it.

I know all this because I have adorable photos of my three-year-old daughter and five-year-old son cuddling Molly, our best laying hen, in the backyard. Molly died of natural causes six years after we last saw an egg. Fluffy, Rusty, Muffy and Twinkle had similarly long and semi-productive lives, which is no small feat given the preponderance of foxes in the suburbs of Melbourne.

The hard lesson from the summer that Scott Morrison only just bumbled his way through is that the public needs and expects good governance in a crisis, and, importantly, when they don’t think you’re up for it, you’ll hear about it long and loud. At the very least they expect the prime minister to be in the country.

In that respect, at least, Morrison is going well. He couldn’t get a flight to Hawaii right now even if he wanted one. In the other? While it’s still early, his stocks appear to be rising. •

The post Fending for ourselves appeared first on Inside Story.

2 or 3 of the bakers have been closed, everyone down together. There were 7 deaths, all men. Arthur has been home from school 13 weeks. Syd had to board away from home on account of railway restrictions. All had to wear masks in shops and in churche [sic] and sit 4 feet apart — and only the minister unmasked.

By this stage of the epidemic, Singleton, 144 kilometres northwest of Sydney on the Hunter River, had been declared an “infected town.” A long battle to have the town’s plight recognised had finally succeeded, but the decision came too late to stop widespread infections and many deaths.

Jennie and her husband, George Colton Smith, had been managing the Singleton Aborigines Children’s Home since May 1910. The missionary couple sought to provide some semblance of conventional family life to the children in their care, some of whom had lived there since infancy. The home, established by local philanthropists, comfortably housed eighteen children. But since the Aborigines Protection Board had taken over its management from the Aborigines Inland Mission in 1915, the number was sometimes stretched to as many as fifty. The children were allowed to attend the local school, but when they turned fourteen the board placed them in “situations” — poorly paid or unpaid domestic employment.

“Restrictions were lifted last Wednesday,” Jennie told Percy. Of her younger children, sixteen-year-old Syd had just returned home after having boarded with a family in Maitland, where he was at school, and twelve-year-old Arthur had returned to the grammar school after five weeks at home. Seventeen-year-old Louise, her elder daughter, had been helping out at the children’s home since the restrictions had kept her from making her daily train journey to Maitland, where she was in her Matriculation year. To add to Jennie’s stress, nineteen-year-old Tilda was also back at home, recovering from typhoid fever contracted at Cummeragunja on the Murray River, where she had been working as an assistant teacher to Thomas Schadrach James, head of the Aboriginal school there.

Easing some of the pressure was the return of her Aboriginal charges to their schooling. “The children (home) went [to school] on Thursday, home five weeks, don’t you pity us with 34 of them. We received 2 more last week, tomorrow four more are coming which means 40.” The board’s demands were unrelenting.

The first Australian news of what we now call Spanish flu was published in the Sydney Morning Herald in May 1918. Some saw it as a German illness, a ruse by “Fritz” to delay or avoid defeat in the war against Britain and its Allies. By July 1918, though, it was clear the disease had caused a significant number of deaths among French and German troops and was spreading rapidly through England and Ireland. Journalists puzzled over the fact that this was a summer disease, unlike the usual winter influenza.

At the beginning of August the disease reached New York; at the end of October it landed in South Africa, with devastating consequences for the white and black populations. Some 1600 deaths were recorded there over a five-week period. In September, after India reported infections, news arrived, terrifyingly for the Australian government, that an infected ship from Canada, the Niagara, had reached Wellington in New Zealand. The epidemic occupied the press for the next three months.

Australia’s distance from Europe and the rest of the world bought it time, giving doctors a chance to learn about the illness before it struck. The disease’s symptomatology and progress were outlined by two New Zealand doctors in the Australian Medical Journal of 22 February 1919. The first case there had been diagnosed in September 1918 when the Canadian passengers disembarked in Wellington, New Zealand. It was of the “ordinary respiratory type,” they wrote, with catarrh in the upper air passages. By November the illness was showing up in lungs and then, “with explosive suddenness, a large proportion of the population was attacked; virulent cases streamed into the hospital in dozens and our resources were taxed to the limit.”

Contemporary accounts reveal the numbers of ill people to have been overwhelming. The NZ government took steps to restrict the illness, prohibiting church attendance and closing schools, barber shops and hairdressers. The population was advised to use mouthwash to prevent the spread of germs.

The Australian government had beefed up its Quarantine Department and commissioning new quarantine hospitals at each Australian port. On 27 November 1918 pneumonic influenza was proclaimed a notifiable disease for ships bringing troops back to Australia at the end of the war, and the many soldiers who showed signs of the disease were immediately quarantined.

For several months this strategy seemed to have succeeded. With deaths from influenza occurring only in the quarantine hospitals, some expressed hope that the pandemic would not break out into the community. But ships were continuing to arrive and the number of cases was increasing. The government recognised that it was only a matter of time.

That didn’t stop a Medical Journal of Australia contributor from decrying as sensationalist any talk of a wider threat and criticising estimates of a worldwide death toll in the millions. How could that be the case when London’s official figure for the seven-week period at the height of the epidemic totalled between 1600 and 1700 deaths? Despite reports of large-scale fatalities in New Zealand, he continued, the official return in the four weeks ending 2 December 1918 was “2458 cases across three of the four health districts.”

Even so, the press as a whole generally accepted that pneumonic influenza would eventually break quarantine and infect civilians. Reports of its virulence continued to arrive from New Zealand, Fiji and Samoa.

Public education had begun towards the end of November 1918. In an interview with the Sydney Morning Herald, a health department official recommended that people inoculate themselves, make use of “respirators” — face masks — and keep “as much as possible in the open air.” Soon a medical consultative council was established, consisting of the leading members of the British Medical Association, still the body representing Australian doctors.

Pneumonic influenza became a notifiable disease on 22 November 1918, a rule soon extended to ships coming into Australian ports. The NSW government appointed its director-general for public health, Dr Thomas Paton, to oversee an “administrative committee” made up of senior representatives from local government, employer groups, unions and retailers, along with the Ambulance Association and the National Women’s Council. The committee proposed public inoculation programs, the manufacture of masks at a shilling each, and what we now call social distancing. “If a person was four feet clear from the affected person’s face,” advised Dr Paton, “the former would not be affected by the disease.”

Federal and state governments met in Melbourne on 27 November. They agreed on measures to accompany infection proclamations at state and regional levels. The Commonwealth was authorised to take control of a state for the period the infection was active, and road traffic would be blocked at its border until a case broke out in the neighbouring state. Provision was made for specialised hospitals, vaccine depots and ambulance transport; volunteers and nursing assistants were organised. Theatres, hotels, picture theatres, race meetings, music halls, churches and schools would be closed. The medical, nursing and military arms of the Department of Defence would respond as needed.

By the end of December, quarantine had been broken. Of seventy-one deaths in the Blue Mountains town of Lithgow during the four months ending 23 December, the Sydney Morning Herald reported, twenty had been attributed to pneumonic influenza. The state was declared infected. Suspicious cases were reported in South Australia, which was also declared infected, and in Melbourne. Border controls were set up between Victoria, South Australia and New South Wales. People travelling between Melbourne and Sydney were directed to return home immediately, and on 25 January passengers travelling to Melbourne from Sydney were tested for the illness. The NSW government ordered all residents within ten miles of the Victorian and South Australian borders to wear face masks while they were going about their business.

The mayor of a city, town or borough, or a president of a shire, was designated as an appropriate health authority and could declare an “infected area” covering a radius of fifteen miles from a case. For the residents of Singleton, the process of gaining such a declaration proved to be surprisingly protracted.

Influenza’s tragedy didn’t extend to regions northwest of Sydney until May 1919, when figures began coming in from outlying areas. Young people, fathers and mothers, entire families were dying. Very young children were orphaned. Singleton’s Dangar Cottage Hospital, which had set up a specialised ward, was filled to its eight-bed capacity. Residents were “fighting the goblin of horror,” as a journalist for the Sydney Sun put it. There was no other way but through.

Hardly a home in Singleton was exempt from the illness. While it might have taken a mild form in many cases, it continued to claim victims. Businesses were depleted. Two of the town’s doctors were ill. On 3 July the editor of the Singleton Argus reported thirty-one deaths in the previous twenty-four hours and 106 newly diagnosed cases. Dr Alister Bowman, Singleton’s government medical officer and a frequent visitor to the children’s home, wanted the town declared infected. But the local council — always lax about these things, according to the editor of the Singleton Argus — was slow to take the matter up, perhaps preferring to believe that the decline in cases across the state meant that the country was getting “over the crest of such cases.” Even when the council did send a report to Sydney stating that the situation was “serious,” the health department still didn’t proclaim the town “infected.”

The editor of the Singleton Argus continued to plead the town’s cause. Matters might be improving in the rest of the state, he wrote, but that was clearly not the case in Singleton. Neighbours might be pitching in to help one another, but resources were low. The bakeries were closed because of illness, and so were the butchers and fruiterers.

The children’s home, long reliant on charity from local businesses, was deprived of the leftover bread and meat that had sustained it for almost a decade. Although it ran its own vegetable gardens and received rations from the government, the donated food had been vital.

Finally, on 12 July, the local council acted on Dr Bowman’s advice and closed the town. Schools had been shut since the beginning of July; now they were joined by theatres, pubs and other meeting places. The town asked the Country Influenza Administrative Council to authorise an emergency hospital at the local school. And finally, just as the epidemic was showing signs of abating, the Singleton Argus announced on 17 July, Singleton was officially “infected.” It was a bombshell for local people after all they had gone through.  A row promptly erupted in the town over the delay and the council’s muddled approach.

The closures had not happened when the town most needed them, as Dr Bowman later pointed out, before the cases began increasing exponentially. Yet remarkably, as far as we know, there were no infections or deaths at the children’s home. As Jennie told Percy, “I am glad to say we are all well, all had slight colds, nothing serious. Dad’s was the worst but all are doing well.” We can never know whether those colds were a mild case of something more serious.

We know little about the impact of the epidemic on Aboriginal communities. The Aborigines Protection Board’s minute books and reports made little mention of this illness that had closed state borders, business and schools. Reports published by the Aborigines Inland Mission in September 1919 noted the deaths of three people at Bulgandramine, southwest of Dubbo, and three at Moonacullah, near Deniliquin. In Walgett, the missionary himself had been affected and was using the schoolhouse as a hospital. More alarming is a note that a small camp at Denawan, near Walgett, had been “wiped out.”

After the pandemic, a campaign was launched to stop the Aboriginal residents of the children’s home from attending school. Perhaps feelings had changed when the home had been taken over by the Aborigines Protection Board and was no longer an object of charitable interest. A year later the Smiths were sacked, with George accused of unspecified “improper conduct.” Within a week, the board took steps to turn the home into an institution for boys; within three years the home’s premises, long run-down, had been demolished, a feature of the town’s cultural landscape lost forever. •

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About a third of the country’s intensive care beds are in the private system. The government is seeking to increase the national capacity from about 2200 to 7500 beds, which the minister said would be sufficient to meet the worst-case scenario.

His positive messaging may have been partly aimed at reassuring health workers, who have been following horrific accounts — particularly from the United States, Italy and Spain — of overwhelmed systems, shortages of personal protective equipment, and alarming rates of illness and death among health workers.

But at least one medical leader was not reassured. John Hall, president of the Rural Doctors Association of Australia, doesn’t think Australia is on track to have enough intensive care beds, and wants the military to set up field hospitals in areas of need, as has happened in Britain and elsewhere.

“If the international evidence is anything to go by, intensive care units across the globe have been overwhelmed, even when they’ve put good preparations in place,” he tells me. “I don’t think there’s any reason to think Australia is going to be spared.”

Hall is concerned about more than the number of beds; he fears that people in rural, regional and remote areas won’t get their share of beds and equipment. Private hospitals are scarce outside the cities, and intensive care units even more so. Yet non-metropolitan residents — especially in remote Indigenous communities — are especially vulnerable to Covid-19 because they are more likely to suffer from chronic health conditions and live in poor-quality housing.

“We’re concerned for rural Australians about that whole issue of the metropolitan beds being full,” says Hall. “They might have enough intensive care beds in total for the city, but that’s not to say that rural Australians will have access to those beds at any point in time. You might need a separate field hospital set up specifically for taking rural patients, so you’ve got guaranteed access for rural patients.”

Because they’re constrained by shortages of equipment, drugs and appropriately trained staff, rural hospitals have only limited capacity to ventilate critically unwell patients. Hall is worried by reports of some rural hospitals not doing enough preparation ahead of the surge in patients he expects to begin in late April or early May. He has observed a “delusional belief” among some that the novel coronavirus might not penetrate far into rural and remote Australia.

Even in the best of times, it can be difficult to arrange patient transfers from these areas to metropolitan hospitals, Hall says. During a pandemic crunch, retrieval services could easily be overwhelmed by demand at the same time as losing their valuable workforce to infection and illness. While work is under way to increase the capacity of retrieval services, he would like to see much more done, including involving the military in retrieval planning.

Urgent efforts are also needed to boost access to quality palliative care in rural, regional and remote areas. A recent statement from the Australian Covid-19 Palliative Care Working Group said palliative care is an essential component of frontline responses, and called for these services to be boosted as part of operational surge planning.

“There will be a significant demand for palliative care for some of the people who are elderly, frail and have multiple medical conditions, who don’t want to be resuscitated,” says Hall. “They may choose not to be retrieved or sent to an intensive care unit. Those people are going to need access to quality palliative care. We will need extra doctors, nurses, drugs to provide that. Many of these towns have only enough drugs and equipment to manage one palliative care patient at a time.”

At the National Rural Health Alliance offices in Canberra, chief executive Gabrielle O’Kane is also concerned about access to retrieval services and metropolitan intensive care beds, and is hearing from rural and regional doctors anxious about these questions. “Can rural health professionals be assured that there will be fair allocation of intensive care beds for rural people in metropolitan hospitals, should they need them?” she asks. “This situation has made it clear that there are considerable gaps in rural healthcare.”

The National Rural Health Commissioner, emeritus professor Paul Worley, is worried too. As he tweeted on 31 March: “Are you, like me, angry that rural Australia is having to fight Covid with one hand tied behind its back? The constricting rope is health workforce shortage. 61 GP vacancies in SA alone. We can’t just do more of the same. Let’s use this time to make our rural health system stronger.”

The Royal Flying Doctor Service is already feeling the impact of the pandemic. It transported forty-six patients with Covid-19, aged fifty-eight on average, between 20 February and 29 March, according to executive director Frank Quinlan. Transporting these patients takes longer and costs more because of the extra cleaning required for infection control.

Quinlan welcomed the news of public and private hospitals working together to expand capacity, and said the RFDS was also working hard to build its own capacity, bringing on additional resources, including locums, pilots, engineers, contractors and clinical crews.

“We’re planning for the worst and hoping for the best,” says Quinlan. “Planning for the worst means we have to consider the possibility that both aircraft crews and clinical crews could become ill and that will place pressure on already challenged resources. All of our planning has revolved around enhancing and building up that capacity.”

Quinlan believes it is too early “to be either comforted or alarmed” by trends in Australian case rates, but is encouraged by Australians’ response to calls for social distancing. “It is an opportunity for the community to take control of this crisis,” he says. “That creates the sense that we’re all working together.”

Under the deal announced by Greg Hunt this week, the private sector must act as not-for-profit organisations for the duration of the crisis, and open their books for audits. In return, governments are guaranteeing their viability during the life of the agreement.

Private hospitals will contribute 30,000 beds and 105,000 full- and part-time hospital staff, including 57,000 nurses and midwives, to the pandemic response. The Commonwealth was budgeting $1.3 billion for the arrangement, but the figure was not capped and, the minister said, “if more is required, more will be provided.”

Australian Healthcare and Hospitals Association chief executive Alison Verhoeven welcomed the deal as “a very necessary and sensible move.” “The whole arrangement is really good to see — state governments, the Commonwealth government and the private sector agreeing to work together in a really coordinated way for the benefit of the community.”

Stephen Parnis, an emergency physician at three Melbourne public hospitals and a former vice-president of the Australian Medical Association, says there can be no one-size-fits-all in bringing the sectors together, not least because of the diversity of private hospitals, which range from small day surgery facilities to fully equipped tertiary services.

To work most effectively, arrangements will need to be made locally, he says. “It may be that the private hospital takes on the standard hospital load to enable the public hospital to become sectioned off and treat Covid patients.”

A massive logistics exercise is under way, together with urgent efforts to boost health workforce numbers and extend critical-care training. Health workers, academics and communities are discussing the ethical dilemmas that lie ahead, spurred by reports from Italy and elsewhere of health workers left weeping and traumatised from having to make life-and-death decisions. When ten patients need lifesaving ventilation but only one machine is available, who is chosen?

At times like these, some groups — including disabled people and Aboriginal and Torres Strait Islander people — are at increased risk from both Covid-19 and systems that have a long history of causing them harm.

The Australian Indigenous Doctors’ Association, or AIDA, has received reports of Aboriginal people experiencing racism and exclusion from health services during the pandemic. It has called for Aboriginal and Torres Strait Islander patients to be tested and treated ethically and equitably for Covid-19. “Aboriginal and Torres Strait Islander Peoples’ lives, health and wellbeing cannot be put at risk because of underlying racism and prejudice,” says the association.

According to Janine Mohamed, a Narrunga Kaurna woman and chief executive of the Lowitja Institute in Melbourne, it is in high-pressure situations that non-Indigenous health workers are most likely to make kneejerk reactions based on embedded negative views of Aboriginal people.

“We have seen this already play out in our reduced access to transplants,” she says. “We know that Aboriginal people don’t get the same pathways of care. At this time, more than ever, cultural safety has to be at the forefront of health professionals’ minds. In September, when this pandemic is finished, what I don’t want to read is that Aboriginal and Torres Strait Islander people who needed intensive care were left to die. We have to do whatever we can to ensure that preventable deaths do not happen.”

Similar concerns are also worrying Bronwyn Fredericks, a Murri woman and Pro-Vice-Chancellor (Indigenous Engagement) at the University of Queensland, who stresses that Aboriginal and Torres Strait Islander people must be involved in developing pandemic ethical protocols for resuscitation and allocation of lifesaving interventions.

“I’m concerned for my parents, my partner, other family, friends, community members, and even myself,” she says. “I know that if medical interventions become rationalised and if we have coronavirus that there is the possibility we wouldn’t be offered lifesaving treatment if pitted against others, and that we would be offered isolation and palliative care instead.”

Fredericks is also worried that age could be a factor in determining access to care. “[This] fails to consider that that Elder in front of them may not just be a partner, or grandparent, uncle or aunt, but also be a precious and rare repository of language or law, music, art, medicine, knowledge, philosophy and more,” she says.

“They might be one of only a handful of people who hold this knowledge not just in the community, but in Australia and in the world… It needs to be asked, are we prepared for us, and the world, to lose this by rationalising lifesaving interventions based on availability of resources and age?”

While Fredericks welcomes the hospital deal in principle, she wonders about the implications for Aboriginal and Torres Strait Islander people. “The coronavirus itself doesn’t discriminate; it is society’s structures and people that do. The deal to open up private hospitals for all must also now ensure access for all too,” she says.

The perfect storm created by the pandemic is driving integration and cooperation across the health system in ways that were previously inconceivable. Suddenly, population-wide telehealth and other innovations that have been waiting in the wings for years are a reality. A government better known for health cuts than health innovation may go down in history as having introduced some of Medicare’s most significant reforms.

The Australian Healthcare and Hospitals Association’s Alison Verhoeven is keen to ensure the momentum continues beyond the pandemic. While some not-for-profit hospitals have a long history of working for health equity, Verhoeven would like to see the wider sector stepping up.

“At the moment, private hospitals support a population group that can afford to pay for their services,” she says. “What we have seen with this week’s funding announcements is a recognition that they are part of the public system, partly subsidised by the public purse, so they have an obligation to contribute to the health of the wider system.

“We hope that, longer term, private hospitals might continue to support some of that social obligation. It’s important that they engage in the dialogue that we need to have at a national level about supporting the health of the most vulnerable people in our community.”

More broadly, Verhoeven hopes the pandemic will also lead to wider societal changes, tackling problems that have been thrown into sharp relief by the pandemic, such as the casualised, insecure health workforce and the privatisation of essential services.

The Rural Doctors Association’s John Hall hopes the groundwork is being laid for lasting changes in the relationship between private and public health services. He would like the public sector to be more responsive and engaged in collaboration with private services, including general practice, radiology and pathology.

“My view is that public and private haven’t collaborated well enough in the past; we have seen that play out in the regions. For example, a private radiology firm might want to co-locate with a public hospital in a rural town but the negotiations have fallen over because the public sector is notoriously bad at working out collaboration with the private sector.”

Hall also describes public patients being transported long distances from regional centres for essential cardiac services that could have been provided by private services locally. This has often meant huge additional costs for patients and families because of the travel involved. “For a public hospital to use the private catheter lab is a really good example of where the private and public sectors could work together to provide an evidence-based service to the community,” he says.

Hall says this must be a transformational time in driving greater cooperation between health systems and services. “This is going to be a war for rural doctors and rural health services. We would like to see barriers broken down so everyone can put in their best efforts to win the war.”

In Tasmania, Geoff Couser, an emergency physician in public practice, questions whether it is appropriate to refer to a “private hospital system” at all. He prefers the term “federal public hospital system” given the large public subsidy the private sector receives through Medicare, subsidies for private health insurance, support from the Department of Veterans’ Affairs, and tax exemptions for religious institutions.

The pandemic crisis is a perfect opportunity for making clear that any sector receiving a significant amount of public money has a responsibility to contribute to the wider public good, he adds. “It is about getting the best value for that public money every step of the way. We need to have that sense of stewardship and responsibility on a fiscal level to taxpayers, and responsibility to patients.”

Couser also highlights inequities built into the system. Patients with private health insurance can tap into the “federal public hospital system” and get a colonoscopy next week, he says, while those relying on state public hospitals face long waits.

Despite apprehensions about what lies ahead, Couser is enjoying some relatively quiet time before the storm hits. Presentations in the emergency department are down, perhaps because more people are staying home. This has left time for preparation, and also reflection, including about how he hopes the crisis will bring transformational change for health systems and society more widely. “I hope that we will not waste the crisis,” he says. •

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The video might regrettably have been removed from her Twitter and Instagram feeds — pious advocates for the poor and downtrodden were outraged by its supposed insensitivity — but Madonna’s insight is backed by the academic heft of Walter Scheidel’s recent book, The Great Leveler, an account of economic inequality from the stone age to the twenty-first century. Drawing on income and wealth data over as long a period as possible, Scheidel makes the persuasive if dispiriting case that only mass-mobilisation wars, transformative revolutions, state failures or catastrophic pandemics have ever led to greater economic equality. (The shifts triggered by the second world war are a prime example.) Otherwise, elites use their capacity for rent-seeking, capital accumulation and state control to bend the system to their advantage.

The fear that the Covid-19 pandemic will indeed turn out to be a great equaliser is manifest in the increasingly desperate mantra that the pandemic will soon be over and everything will return to just as it was before. It is evident in Trump’s forlorn hope that churches will be full by Easter and the United States “opened up.” It’s also there in Scott Morrison’s repeated invocation of “the other side” at his 29 March press conference, and his hope that “businesses can get through and be there on the other side.” At least Morrison’s time frame was a more realistic six months.

It remains to be seen whether the economic changes necessitated by Covid-19 result in a lasting increase in equality. It will partly depend on how long the economic hibernation lasts, and that too remains to be seen.

As the week ended, chief medical officer Brendan Murphy cited tentative signs that Australia might be showing “a somewhat slowing of the growth in the epidemiology curve.” For the whole of March, Australia has been teetering on the brink of untrammelled community transmission. On one side of that threshold, every person confirmed to be infected is immediately isolated and vigorously followed up, with testing of all contacts who may have been exposed; combined with extensive testing of possible cases across the community, this approach can contain the epidemic spread. On the other side of the threshold, contact tracing becomes a drop in the bucket compared with the number of cases identified on the basis of their symptoms. Asymptomatic cases (about 60 per cent of SARS-CoV-2 infections) will likely never be identified, and the focus shifts to isolation and care of those who are sick.

In early March, Singapore pleaded for the “critical, clear, and present danger to all countries” to be recognised, and for its model of contact tracing and isolation to be emulated. At the end of March, the island state announced that its TraceTogether contact-tracing app would become open source and available to the world. Developed by GovTech, the Singapore government’s agency for digital transformation, the app uses bluetooth to enable voluntary users (620,000 Singaporeans so far) to keep track of all other users they come into close contact with. (Think of it as an always-on dating app, but with a very different aim in mind.) This data is stored anonymously and encrypted on the phone, though once the user is diagnosed with Covid-19 the data is unlocked by the Ministry of Health and all close contacts alerted.

The system depends on two things: a sufficient level of trust in government, and a recognition among potential users that they will benefit from being contacted quickly if they have been in close contact with a Covid-19 case. Unlike proposals elsewhere to use previously covert intelligence surveillance for Covid-19 tracking, the Singapore innovation seems to manage the balance between privacy and altruism. Already, the Covid-19 Digital Rights Tracker has identified nineteen countries where the pandemic has resulted in new digital-tracking measures, and most have eroded privacy significantly.

If (and it remains a very big if) Australia does become one of the few countries to contain the epidemic at relatively low levels, it will be a tribute to the public health system and to all those involved in this great effort. But the immediate relief will come with significant longer-term costs. Minimising the first wave of the epidemic will certainly mean that the capacity of critical care units in the health system isn’t overwhelmed, and that will minimise deaths. It will also mean that only a small fraction of the population becomes infected.

But those who become infected and then recover are the only part of the population guaranteed to be immune (and it is not yet clear whether that immunity will wear off over the course of months or years). For the remainder of the population, any new case of Covid-19 has the potential to set off a new wave of infections. As physical-distancing restrictions are relaxed, the potential for rapid spread will return, so rapid detection, isolation and contact tracing will remain critically important.

And as the world responds at different paces to epidemic control, a critical question will be when Australia deems it safe to relax entry restrictions from other countries. On Saturday China banned the entry of non-nationals following its eradication of new domestic cases; meanwhile, as was eminently predictable, the Covid-19 epidemic has become rampant in the United States. It may well prove feasible to allow travel between Australia and China long before Australia–US routes can be opened up.

Aside from contact-tracing apps, the technologies with the most immediate impact on the future of epidemic control will be in diagnostics. Already, new Covid-19 tests have appeared on the market, and alternatives to existing polymerase chain reaction, or PCR, tests are being developed or rolled out, including antibody tests that could be both rapid and self-administered.

Abbott has adapted and taken to market its toaster-sized ID Now diagnostic machine, though only in the United States for now. Like PCR tests, it tests for the genetic material of the virus; unlike PCR, which requires a thermal process to separate the strands of DNA, it operates at a constant temperature and is both compact and rapid. Abbott claims it produces positive results in five minutes and negative ones in thirteen.

Similarly, a new Covid-19 detection cartridge has been developed for GeneXpert, a rapid PCR assay machine small enough to sit on a desk and rapid enough to produce results in an hour. The GeneXpert machine has proved enormously useful in detecting TB — especially multi-drug resistant TB — in many developing countries.

When sophisticated diagnostics can be brought to local level they can transform the speed and flexibility of the local response. I vividly remember visiting a small health centre on Zimbabwe’s border with Mozambique about five years ago. The centre really was at the end of the road, a simple building run magnificently by two nurses on a shoestring. (Often they couldn’t report in to the district hospital because they had no phone credit.) But there, with its red light blinking in the corner, was a small PIMA CD4 machine that enabled on-the-spot diagnosis of the immune status of HIV patients. Instead of the usual procedure of sending samples off to a distant lab, which holds up treatment and monitoring, the whole process could be carried out locally (although it did rely on the systems that kept the machine functioning, with all its relevant consumables).

Beyond testing, the two wildcards in the evolution of this pandemic are treatment and vaccines. Not much has been heard in the past week about prospective treatments of those who become sickest with Covid-19, and that’s because a number of candidate treatment drugs are rapidly moving to trial phase. Shortcuts can be taken in treatment development, including speeding up regulatory approval, sharing information, and ramping up resources in the chain from basic science to manufacturing. But there is no avoiding meticulously designed and implemented trials to see whether a drug works. Medicine is littered with drugs that showed initial promise either in the test tube or even in initial human trials, but turned out not to be effective or even to worsen the disease.

A number of new vaccines are also well on the way to trialling, and they too will need careful assessment. Among the proposals to speed this process up is a call for approval of “human challenge” trials for Covid-19. Once a candidate vaccine is found to be effective and safe in animal models and first-stage human trials, it is normally tested in a larger-scale Phase 3 trial on people who might be exposed to the pathogen. These trials need to be large enough and last long enough to capture sufficient numbers who might have been exposed and detect differences in infection rates between vaccinated and unvaccinated trial groups. One way of speeding that up is to deliberately infect the trial group and then see how many of those receiving the vaccine develop the disease compared with those receiving the placebo.

In this case, the argument for a human challenge is that the risk of catastrophic infection will be minimal in a young and healthy group of subjects. That may well be true, but the risk will not be altogether eliminated. It’s hard to see an ethical argument for human challenges when the spread of Covid-19 is still rampant and large-scale exposure to the virus likely — but that may change if a vaccine is only ready for trial after the rate of new infections has died down.

From health systems to economic responses, clear pathways are emerging and many of them point to greater equality. Equitable income support, distributed diagnostics and open source solution software are all pointers to a communal, global levelling.

The “new normal” has become a dreadful cliché. Try Giorgio Agamben’s “state of exception” instead. It may give a better sense of both the possibilities and the dangers that lie in that liminal space, the brink on which we are teetering. •

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An ethical framework for dealing with the pandemic has international, national, community and personal dimensions. They play out in the familiar conflict between the needs and desires of individuals and of the group, and in the ability of the well-off, and well-off countries, to get more benefits than the disadvantaged. Decisions made by policymakers in times of crisis, and how the community responds hold up a mirror to our national ethos. Do we like what we see?

The World Health Organization sees three broad ethical issues. Who gets priority access to healthcare resources? What are the obligations of healthcare workers in light of the risks to their own health? And how do we balance necessary isolation and travel restrictions with protecting the rights of individuals? When a pandemic has dramatic economic impacts, that list should also include the question of who gets financial assistance. Affordable childcare options, internet access and room to work at home create a gulf between rich and poor.

Some of the ethical issues should be relatively straightforward. We need to ensure that some groups of people aren’t more likely to get tested than others simply because of their status or connections. We need to keep cracking down on people who flout instructions about social isolation and quarantine, especially when the capacity of certain groups to protect themselves and their families is already compromised by the essential work they do — not just as doctors, nurses and carers, but also in transport and delivery, cleaning and food services, and garbage collection. Hoarding, too, is anything but victimless during a pandemic.

The thornier ethical dilemmas arise when the number of seriously ill people requiring acute care rises to a level at which hospitals and healthcare facilities cannot cope. That has been the case for several weeks in Italy and is increasingly the case in New York City.

In Australia, the government and its advisers have provided reassuring advice about the ability of hospitals to increase their surge capacity, and the rationales for how we can flatten the curve to avoid the pressures on intensive care. But if the most worrying scenarios were to play out, Australian hospitals would not have the capacity to accommodate possible demand, and some types of care — specifically intensive care, ventilators and respirators — would need to be rationed. This would not be a discretionary decision but a necessity, and the level of rationing would increase if significant numbers of healthcare workers were infected.

Efforts to increase testing and social isolation will come to nothing if a similar level of investment is not put into protecting healthcare workers in hospitals and carers elsewhere in the community. Yet daily there are stories about the severe lack of appropriate personal protective equipment. This adds to the stress and anxiety of people who face the constant risk of infection and worry about their own families. At their extreme, the shortages could have the dreadful consequences highlighted by stories from Europe.

In deciding who gets access to rationed care, the overriding principle will be one of utilitarianism — maximising the benefits produced by the scarce resources — in the knowledge that available intensive care treatments are by no means guaranteed to produce the desired outcome.

In the United States, a conversation is already taking place in public about how to ensure, when lifesaving resources are scarce, that hospitals have consistent, transparent guidance for patient care. These “crisis standards of care” prioritise the survival of the group over the survival of the individual patient during disasters. But although the US Centers for Disease Control and Prevention has outlined general principles, it’s up to individual hospitals, health systems and states to decide policy. The result is a patchwork system, with states including New York and Minnesota having drawn up detailed guidelines for allocating resources but others having yet to confront these tough issues. If the pandemic and ventilator shortages get as bad as the worst predictions, some envisage palliative care being offered to people who might have survived with intensive care.

In Italy, the peak body for intensive care medicine has published a grim guide stating that “resources may have to be used first for those with a higher probability of survival and, secondly, [for those who have] the most years of life left, and offer the maximum number of benefits to the majority of people.” Others reach the same conclusions. “If we give scarce treatments to those who don’t stand to benefit (and have a high chance of dying anyway), then not only will they die, but those with higher likelihood of survival (but require ventilator support) will also die,” says Lydia Dugdale, director of the Center for Clinical Medical Ethics at Columbia University. “It’s not fair to distribute scarce resources in a way that minimises lives saved.”

In Australia, rationing has been mentioned in passing, but whatever expert discussions are taking place are out of public view and don’t involve public consultation. In drawing up guidelines and making these decisions, hospitals and doctors will consider the number of co-morbidities, the severity of respiratory failure and the probability of surviving prolonged intubation — factors that are generally linked to the patient’s age. But as medical experts both in Australia and overseas have noted, the primary criterion for rationing should be the chance of survival, whatever a patient’s age.

Being on life support in intensive care is challenging even for young, previously healthy people; patients often require fifteen to twenty days of ventilation and then a slow weaning. Intensive care is hugely resource-intensive, involving sophisticated equipment and large numbers of trained staff. Even the process of intubating a patient to go on a breathing machine presents a major infection risk to the doctor involved.

If a patient in these circumstances is not doing well, is it ethical to give the ventilator to another patient with a better chance of survival? Who would make that decision and what would guide them? This question might be hypothetical now but could become real in a very short time.

Little discussed is the extent to which the use of resources for treating patients with Covid-19 limits the treatment of patients with other medical conditions. Patients will continue to present with trauma, heart attacks, strokes and even complications arising from seasonal flu, and they too will need intensive care and ventilators.

The challenge of balancing the needs of Covid-19 patients and patients with other serious conditions applies also to medicines. Media hype about the possibility of treating coronavirus infections with chloroquine, pushed along by Donald Trump in the United States and Clive Palmer in Australia, has led to international shortages of a drug normally used by patients with serious conditions like lupus and rheumatoid arthritis. Here in Australia, people have purchased asthma medications in case they need them, reducing availability for people with chronic respiratory diseases.

The life-and-death decisions that rationing will force will be made more difficult if doctors are hamstrung by unnecessary procurement failures and shortages, if the system is rife with access disparities for some segments of the population, and if there is insufficient support and guidance for how such decisions should be made.

International organisations like the WHO and the OECD have called for a global effort and international cooperation to tackle the coronavirus pandemic. However, a pandemic inevitably means that countries look inwards to their own needs. President Trump’s policies have worsened the problem in the United States. Developed nations are all reeling from their own disease burden, which has been exacerbated in some countries, including Australia, by a lack of forward planning that leaves them facing shortages of testing reagents and kits as well as medical equipment. The situation will be much worse for developing countries.

In the weeks ahead, will the world be willing to share resources, as China has done for Italy? Or will there be isolationism, as seen in reports that the Trump administration was seeking to buy a German vaccine “only for the United States”? Will Australia look to see what help it can offer to Papua New Guinea and Pacific island nations? And who will ensure that the millions of people in refugee camps get the help they need as coronavirus spreads relentlessly?

The American College of Chest Physicians’ statement on care during pandemics and disasters makes the case that focusing on ethical principles is not a luxury but an obligation, necessary to engender trust and alleviate moral distress and burnout in providers. Trust is in short supply these days, as scarce as personal protective equipment for healthcare workers; clear principles can go some way towards restoring it.

That is why Australia needs explicit guidelines for how it behaves internationally, nationally and at the community level when needed resources are scarce. These must be ethically grounded, transparent, publicly developed, effectively communicated to all, and regularly reviewed. Because one day history will hold us accountable for what was done and why in this time of pandemic disease. •

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The reality is quite different. The vast majority of Australia Covid-19 cases acquired overseas had a recent history of travel to Europe or the Americas, or arrived on cruise ships such as the Ruby Princess. Hardly any (in fact none, as far as I can determine) were new migrants to Australia.

It could scarcely be otherwise. Australia (or at least some Australians) welcomed 162,000 migrants in 2019. The same year saw forty-two million passenger arrivals. On average, a Boeing 787 landing in Australia with a full load of 300 passengers contains just one permanent migrant.

This is the contradiction within the thinking of immigration restrictionists. While many like to cast themselves as “left behind” “stayers” — in contrast to “rootless cosmopolitans” — lots of them enjoy international travel. This was strikingly illustrated by the Brexiteers’ attachment to the traditional blue-covered British passports — hardly something that would matter to anyone content to stay in their home country.

More generally, the push to reduce international migration has been matched by all-out efforts to promote tourism. Scott Morrison embodies these contradictions. As managing director of Tourism Australia he famously asked, “Where they bloody hell are you?”, inviting the entire world to enjoy our beaches and charming cities; as prime minister, he cut the immigration intake by 30,000 (about one day’s worth of passenger arrivals) declaring “enough, enough, enough… The roads are clogged, the buses and trains are full.” Tourists, of course — who are by definition engaged in travel — use our roads and public transports at least as much as permanent migrants.

It’s not only migration that ethnonationalists have in their sights, but also any kind of international cooperation (unless it involves waging war). Greg Sheridan, foreign editor of the Australian and admirer of Hungary, Poland and other anti-democratic regimes, says that “coronavirus is the hunter-killer enemy of globalisation”:

The centre of every citizen’s sense of accountability for this virus is their national government. No one asks: what is the Indian Ocean Regional Association for Co-operation doing about this? They ask: what is Canberra doing?… When the Morrison government first banned direct travel to Australia from China, Beijing was furious. Then a lot of countries did the same.

That was on 18 March. The next day, the sidelining of “Canberra” began, with the premier of Tasmania announcing that the state would effectively be closed to interstate travellers. South Australia, Western Australia and Queensland quickly followed suit, with Queensland introducing an internal border to protect vulnerable Indigenous communities in the Cape York Peninsula.

As the federal government floundered, state governments increasingly disregarded its edicts, closing schools and accelerating the process of locking down the economy. The same was true in the United States, where state governors have responded to federal inaction with increasingly drastic measures of their own.

The absurd, but inescapable, implication of Sheridan’s argument is that we should recognise state difference by unwinding not only globalisation but Federation and breaking Australia up into six to eight separate countries. But the reality is that viruses pay no attention to states, nations and confederations. The appropriate restrictions on travel, and other preventive polices, will be determined by physical realities, whether or not they respect national boundaries.

The other crucial factor is what public policy analysts described as “state capacity.” This is the ability of a government (supranational, national, state or provincial) to formulate a coherent response to a problem, such as a pandemic, and the effectiveness of the tools at its disposal. The coronavirus crisis has revealed huge gaps in capacity at the federal level in Australia. The much touted Border Force, for example, has proved incapable of implementing basic health checks at our borders. (The blame-shifting between Border Force and the NSW health department over the Ruby Princess fiasco is a prime illustration of weak state capacity.) Similar breakdowns are even more evident in the United States.

Inevitably, state-level governments have stepped into the breach, with varying levels of effectiveness. Readers can make their own judgements as to how they have performed. Strikingly, though, a crisis seemingly tailor-made to enhance the power and prestige of national governments has, if anything, done the opposite, even as the need for action by all levels of government has become so much more urgent. •

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In a piece for the Mandarin this week, Professor John Shine argues the Australian government must release the data upon which its outbreak response strategy is based. In Britain, he notes, the Government Office for Science releases the scientific and technical advice given to government decision-makers during emergencies.

This poses thorny questions about mathematical modelling. The week before last, we saw an effusion of home-brew graphs on Twitter, produced by “armchair epidemiologists” whose quantitative skills were unguided by any subject matter knowledge.

In response, public health experts spent a lot of time engaging on social media, forcefully arguing “don’t try this at home.” The danger is that such models generate alarm and create a political constituency for control measures that are simple and decisive, like school closures.

In the fight against home-brew graphs, a key message was that small changes in a mathematical model’s assumptions and initial values can produce wildly divergent outcomes.

The same caution applies to models developed by genuine experts. We saw that with the publication of a study by Imperial College influenza expert Neil Ferguson, which suggested only society-wide “lockdown” could prevent hospitals being completely overwhelmed.

While recognising Ferguson’s expertise, critics argued the model overlooked key facts about how control measures are implemented in practice. In particular: the empirical fact that China brought its own epidemic under control primarily via aggressive contact tracing.

It is questionable whether policymakers understand that model outputs are artefacts of a process of construction, and not empirical findings about the actual epidemic. Models generate predictions that are subject to significant uncertainty, as seen in confidence intervals calculated on the basis of choices made when the model was put together.

All of these problems are multiplied when we call for governments to release and defend the rationale for their epidemic planning. Journalists need to have (or very quickly develop) the epidemiological and statistical literacies needed to interpret and evaluate these models, and the skills to explain their methods and findings to readers.

Journalists have handled this problem by interviewing first the model’s developers, then an independent expert who praises its findings, then another who criticises its limitations. We’ve seen this during the climate change debate as well. It does readers no favours. They need to develop their own literacies in order to participate in public debate over control measures and the material impacts they will have on all of our lives for a long time to come.

The prime minister and the chief medical officer have had a string of nightmare press conferences. My own sense is that they are struggling to communicate a rationale that depends on an assessment of the evidence that is complex and prone to causing panic.

In the absence of that rationale, though, people struggle to understand the recommendations. Professor Shine and Professor Tony Blakely are correct to argue the government urgently needs to communicate the “missing rationale” for our Covid-19 response.

So how could we do this?

Every year, in May, the government releases an extraordinary amount of data, all in one hit, justifying great changes in our social arrangements on the basis of multi-year predictions about society and the economy — I’m talking about the federal budget.

The government could and should use similar methods and capacities to communicate the missing rationale. These include a day-long “lock-up,” essentially an extended press conference with an embargo on reporting until the end of the day.

Before the evidence is released publicly, a pandemic lock-up would allow experts time to walk journalists and other community leaders through the evidence on which our epidemic response is based — the data, the methods and the findings — and build the basic literacies that are needed to understand and evaluate them.

The Parliamentary Library should be commissioned to do what it does best — summarise the evidence and translate complex policy into everyday language.

Lastly, the health minister Greg Hunt should front parliament and present the rationale. As I’ve argued, understanding is an essential precondition for collective action. And as the school closures debate has demonstrated, political participation continues even in a crisis. •

BONUS LINK

Corona-land is a research-based interactive simulator that helps people in the community develop their literacy in both modelling and epidemic dynamics.

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Any route back from, or through, the abyss will be hard. Neutering Covid-19 is essential to minimising the pandemic’s human toll and economic hit, each measured in lost lives. A further test lies in the variegated nature of the emergency: global and national, and not just threatening health, livelihood, business, finance or governance, but all of these together. Europe’s states are stretching to their max, with no certainty that will be enough.

In Britain’s case, early caution has given way to urgency as the silo-busting scale of the challenge dawns. The government’s initial strategy projected four phases in tackling the virus: “contain, delay, research, mitigate.” Its public faces were the chief medical and scientific officers, Chris Whitty and Patrick Vallance, flanking Boris Johnson and giving the prime minister the ballast that he can’t help but seem to lack.

The pair’s kindly gravitas made even stark detail and advice sound reassuring. Then, a fortnight ago, though it seems years, came a perceived stumble over “herd immunity” — the notion that harmless infection at scale among the fit populace would safeguard the whole, allowing more gradual management of the epidemic by “flattening the curve” and thus keeping deaths to (it was whispered) around 20,000.

The theoretic case was marred by uneven (or outright poor) messaging. Some critics baulked at the idea in principle, others noted the contrast with Singapore, Taiwan, South Korea and Hong Kong’s proactive coordination, a lesson from SARS in 2002–03: “test, trace, isolate.” Equally, Britain’s resistance to the incrementally tighter lockdowns of European states made it seem an outrider nearer home. Scientific disquiet and media debate were prompting hints of a change when its accelerant materialised: a paper by the mathematician Neil Ferguson and colleagues at the MRC Centre for Global Infectious Disease Analysis, published on 16 March to immediate alarm and refocus.

Drawing on Italy’s medical trauma, its data modelling found that a staged approach would result in Britain’s health services being overwhelmed, and a death toll of perhaps 260,000. The policy priority had to be suppression of the virus, not mitigation:

Perhaps our most significant conclusion is that mitigation is unlikely to be feasible without emergency surge capacity limits of the UK and US healthcare systems being exceeded many times over… [Thus] epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound… [Even] those countries at an earlier stage of their epidemic (such as the UK) will need to do so immediately.

From that Monday, directives — initially poised between advice and command — tumbled over each other at the now-daily briefings: self-isolation of the over-seventies, social distancing, home working, school closures, venue shutdowns (pubs, restaurants, theatres, cinemas). Since these measures would push many businesses and workers towards liquidation, chancellor Rishi Sunak announced £330 billion (A$664 billion) of loan guarantees to keep Britain’s largely service economy afloat. His acclaimed budget’s £12 billion to fight the epidemic, a week earlier, was already a distant age.

The blizzard of initiatives culminated on Friday with two more bazookas and a depth charge. After talks with business and unions, Treasury’s “job retention scheme” committed to paying 80 per cent of employees’ wages (up to a monthly £2500, or A$4970) for three months, plus sick pay to the self-employed and welfare supplements. Some details are still to be nailed down.

By then, so punch-drunk were newshounds that the Bank of England’s launch of £200 billion in quantitative-easing bond-buying and an interest rate cut to 0.1 per cent were barely noticed outside the financial pages. These few life-changing hours also saw the lightning creation of a 320-page coronavirus bill with bracingly wide statutory powers (for example, detention of miscreants or the mentally ill to enforce lockdown).

Over five extraordinary days — surely destined to produce a companion to John Lukacs’s classic Five Days in London, May 1940 — health, financial, business and governance emergencies melded. And a further, intimate emergency joined them, for the cumulative effect of the PM’s daily checklist was to impose on families and individuals across the land an obligation to reconfigure their lives for an indefinite period. “Unprecedented,” rare in this old country’s political discourse, had its moment in the sun. Only the 1940 crucible of the “people’s war” had vague plausibility as an analogue, not just via its jumble of mythicised memory.

A colossal week had already called forth a touch of martialism in a Britain always ready for the parade ground. Johnson declared “war” on the virus and pledged to “defeat” the “invisible enemy.” Then his Dad’s Army–ish “send coronavirus packing,” harmless as it was, let slip his bonhomous urge to test tonal etiquette, reprised in a wayward quip promoting ventilator output as “operation last gasp,” which many affect to find enraging.

More intriguing was the glow around hitherto mundane “key workers,” evidently a capacious bunch going well beyond the uniformed, badged and suited (with even some journalists passing muster). The British state has often looked threadbare over these two decades, at times an outright failure. This latest spine-stiffening exercise, forced by impossibly acute domestic demands, incorporates its own version of herd immunity.

By last weekend, the country’s twin paths — stepping into a new economic era while approaching a door into the medical dark — were palpable. Yet daytrippers lured by bright weather packed rural scenic spots and London parks were still in la-la land, their blithe spirits at last pushing a brittle Number 10 towards quasi-curfew. Johnson’s live Monday evening broadcast, delivering its you must stay at home mantra with passable high seriousness, was as stern as this natural libertarian can manage. (“The way ahead is hard… Join together to halt the spread of this disease, protect the NHS, and save lives.”) The exceptions to staying in — buying food, medical need, essential work, a lone bout of exercise — were clearer than the compliance regime. But the twenty-seven million–plus who watched on TV alone, almost half the population, could have no doubt about the main point.

Hours earlier, the coronavirus bill, its terms and two-year lifespan agreed with opposition parties and awaiting assent by the Welsh, Scots and Northern Ireland assemblies, was given sober treatment by a depleted Commons before passing without a vote. After the House of Lords’s brief scrutiny and the Queen’s sign-off, it grants ministers “wide and robust powers” (provisional as they are intended to be) to subdue Covid-19. The second week of this latest British-style revolution — for such it is, only three months after the previous one — had begun.

These volcanic events, their perilous background fortifying social unity insistently cultivated by broadcasters — have eased the political temperature. A YouGov poll released on 24 March put Johnson’s favourability rating at 55–35; Ipsos MORI on 19 March showed 48–41 satisfaction with the government (the first such positive score since 2010). A tilt to the Conservatives is plain. But incumbents often benefit when a crisis breaks, and such findings could well change as pressures on health staff and equipment shortages rankle, and Labour’s new leader (probably the London lawyer Keir Starmer) gets a chance to shine.

In play are two other factors: bubbling fury at the government’s early dithering or inattention over Covid-19, and confidence that the state’s massive interventions (several possibly irreversible) presage a decisive left turn.

The former links scientific appraisal of strategic failings to personal weaknesses of leadership, in particular those of Johnson and Dominic Cummings, the PM’s driven, sometimes abrasive senior adviser. Their reckoning is keenly anticipated, as much as Tony Blair’s ever was over Iraq. Their many enemies’ visceral loathing, hitherto ineffective as a political tool, can now draw on epidemiological expertise. That said, the politics of science around Covid-19 is complex and dialogic at many levels, the environment fluid, arguments unsettled. The chips may fall in ways few expect, just as they have in other areas over Britain’s last five years.

The latter puts fresh wind into sails tattered by four election losses, even vindicates the Marxist determinism of the Jeremy Corbyn–John McDonnell circle at the very moment it leaves the stage. Bliss it is in this dusk to be an ageing revolutionary. Their optimism is reinforced by centre-right marketeers who back Sunak’s splurge. But only the Telegraph’s Ambrose Evans-Pritchard grasps the dialectic. He is scornful of Number 10’s “staggering ineptitude” over the pandemic and hails the chancellor’s “executive action befitting the wartime threat that we face” while declaring: “To avert socialism, we must briefly become socialists. We must spend whatever it takes to save free market liberalism.”

What will remain of an economy if the shutdown lasts up to a year, and how the state will keep things ticking, are moot. People everywhere, the bedrock of society, are going to be co-shapers in any outcome. The last paragraph of the report by the team led by Neil Ferguson (he now in self-isolation after being infected) makes a version of the same point:

However, we emphasise that it is not at all certain that suppression will succeed long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time. How populations and societies will respond remains unclear.

All this because a tiny viral agent composed of proteins and nucleic acids became a transformative force to beat them all. The WHO’s Bruce Aylward strikes an uncommon note, but the right one: “This is a new disease. Respect it and learn as it evolves.”

Covid-19 has barely got started. Here as elsewhere, the information deluge’s endless instancy can act as an infectant of its own, blocking awareness of time’s, and life’s, true rhythms. The thought struck home for me on that pivotal day, 16 March, during leg-stretching early-evening fieldwork in six large supermarkets on the fringes of a northern English city, each one clean out of the same everyday staples: pasta, rice, oatmeal, flour, eggs, soap, toilet paper. There was no supply shortage or interruption of delivery, I was told: it was just that some patrons were over-buying.

Such behaviour is not “panicking,” writes the psychiatrist Simon Wessely in that day’s Financial Times, citing 9/11 and the 1918 influenza epidemic to exemplify his case: “We have been warned to prepare ourselves for the [likelihood] of spending two weeks in self-imposed isolation. Stocking up on necessities is… a rational and appropriate response.”

True enough, but those vast bare shelves jolted me into recall of a 1960s joke from communist Poland. A customer at Warsaw’s Smyk emporium asks if this is the cheese section. “Nie, prosze panę, this is the department where we have no sausages. The department where they have no cheese is upstairs.” I could recite the differences in my sleep, but in that moment of psychic dislocation all I could think about was equalisation, and the cunning of history. The years fell away. I had become that customer.

Only a fortnight ago, but it seems an aeon — and that, like its correlatives above, is part of the problem. In this respect, Britain’s share of the global pandemic really is the new Brexit (a word I had hoped to avoid). With the enigmatic Covid-19 in rapid transmission, a repeat of the last four years’ manic inertia will hasten genuine disaster. Soon, these weeks may well come to resemble the “phoney war” whose mental force field was brutally vaporised in 1940 as the actual conflict became all too real. •

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Then the world turned upside down.

As the Covid-19 coronavirus spread from Italy into France, Macron proposed a change of dates for the Tahiti summit and then postponed his trip. I wavered, thinking I could still interview ordinary people rather than presidents and prime ministers. But with airlines cancelling flights and governments closing borders, the decision was soon out of my hands.

French Polynesia’s representative to the French National Assembly in Paris, Maina Sage, returned to Tahiti on 7 March. Four days later, French Polynesian president Edouard Fritch announced that Sage was his country’s first confirmed case of Covid-19. She had sat on a parliamentary commission in Paris with French culture minister Franck Reister, who was one of five members of the National Assembly soon confirmed with the virus. Tested on her return to the Pacific, she was diagnosed with Covid-19 and isolated at home. At the time of writing, French Polynesia is in lockdown, with twenty-five infections a fortnight after the first confirmed case.

The relative isolation of small island nations should provide natural protection from global pandemics, as long as quarantine systems and border controls are in place to monitor arrivals. It’s no small irony that the first confirmed cases of Covid-19 occurred in French Polynesia, Guam, Hawaii and New Caledonia, all of them American and French colonial dependencies (apart from Papua New Guinea, these territories also had the highest rates of HIV infection during the AIDS pandemic). The first coronavirus-related death in the Pacific was announced in the US territory of Guam on 22 March.

Infections have now been confirmed in Fiji and Papua New Guinea, and other island nations are likely to report cases soon.

Naturally people in the Pacific see parallels with the impact of the global influenza epidemic after the first world war. The New Zealand ship SS Talune travelled from Auckland to Apia, the capital of Western Samoa, in November 1918. On board were passengers suffering from a highly infectious pneumonic influenza, known as Spanish flu. Although the ship had been quarantined in Fiji, sick passengers were allowed to disembark in Samoa. An estimated 90 per cent of locals were infected and 22 per cent of the population died.

Today, health departments across the region are urgently sharing basic information about handwashing, social distancing and dealing with coughs and sneezes. But personal hygiene is constrained in countries where easy access to running water and sanitation is limited, especially in outlying rural areas and peri-urban squatter settlements. According to the Pacific Community, “approximately 45 per cent of all Pacific islanders continue to live without access to basic drinking water facilities and some 70 per cent live without access to basic sanitation — the highest of any region of the world.”

While many communities are still unaware of the enormity of the pandemic, years of work to prepare for natural disasters and climate change provide an invaluable base to build on. As I’ve reported in Inside Story, extensive efforts have been put into establishing community disaster committees, mapping local vulnerabilities, engaging women and young people, and developing culturally appropriate community education. The value of this work can be seen today: in the Fresh Water settlement on the outskirts of Port Vila, for instance, community leaders have rigged up bamboo poles to store water for handwashing where individual households lack soap and running water.

When reports emerged of mass infection on the Diamond Princess cruise ship in Japan and the Grand Princess in the United States, Pacific governments moved quickly to ban such visits. Then, in late March, Tuvalu, Nauru, Tonga, Vanuatu and Samoa all declared states of emergency, with other countries to follow.

On 8 March, the Republic of Marshall Islands took the unprecedented step of banning all flights into the country. What seemed an extreme step is now a commonplace measure, as countries close their borders and airlines cancel flights. But the collapse of the global aviation industry poses particular challenges to island nations: national and international carriers are a vital economic lifeline, carrying tourists, imports and exports, development workers and migrant labourers. The decision by Australia and New Zealand to close their borders created problems for the many islanders who must transit through Sydney, Auckland or Brisbane to reach home, but both governments are now waiving the fourteen-day quarantine period for some Pacific citizens to transit.

Pacific seasonal workers face a particular challenge. Many have travelled to work in the largest members states of the Pacific Islands Forum — in New Zealand, under the Recognised Seasonal Employer program, and in Australia, under its Seasonal Worker Programme and Pacific Labour Scheme. Employers in Australia are pushing for their visas to be extended, but social justice and workers’ rights are not high on the agenda.

As Henry Sherrell and Peter Mares have highlighted, this international labour mobility comes at a time of structural shift in the Australian economy towards temporary migration. More than 1.8 million overseas migrants now live in Australia on temporary visas, including New Zealand citizens who are visa holders with work rights under the Closer Economic Relations agreement. Countries like Samoa and Tonga receive more than a quarter of their GDP from remittances sent by their citizens working overseas. With massive job losses in Australia, will temporary labour migrants be welcome again?

As in Australia, interruptions to air and maritime transport, loss of tourism and increased health spending will damage island economies in coming months. Rural communities have the advantage of being able to continue farming and fishing, but other key industries will shed waged jobs. In Palau, Vanuatu and Fiji, for example, more than 40 per cent of GDP comes from the tourism sector. The loss of revenues and remittances will create added pressures on governments already forced to budget for increased health spending. Many countries and territories lack health infrastructure, equipment, qualified personnel and the crucial laboratory equipment to analyse tests on site. Papua New Guinea and some other countries have had to send Covid-19 samples to Australia for analysis, adding delays to diagnosis and treatment.

Even as Australia and New Zealand hunker down, support is needed for health systems in the region. Both countries are jointly funding the Pacific regional coronavirus response plan of the World Health Organization, which includes the WHO Joint Incident Management Team in Fiji. The regional technical agency, the Pacific Community, is the lead agency for public health in the islands region and is working with donors to provide funding, training and support to national governments.

But as borders close and each nation faces its own crisis, Pacific governments will bear the brunt. Even as the first cases are confirmed, governments are dealing with myriad tasks: acquiring laboratory and personal protective equipment; setting up screening services at airports; identifying isolation and quarantine facilities; and developing case management protocols and public awareness campaigns. The danger remains that the spread of infections may overwhelm the health systems of many smaller island states, which lack specialist medical staff and even intensive care facilities at their main hospitals.

Takeshi Kasaim, WHO regional director for the Western Pacific, says that Pacific nations face two major challenges: “First, healthcare facilities could rapidly become overwhelmed, even with a relatively small number of Covid-19 cases. This means that health facilities may not be able to focus on treating the most vulnerable and severe cases. Another major risk is that people with even mild symptoms may come to the health facilities, potentially amplifying the virus’s spread by infecting other patients.”

These weaknesses in public health systems were highlighted by a measles epidemic across the region during 2019. Samoa was worst hit, with eighty-three deaths and 1860 hospitalisations by year’s end, but another 661 cases were reported in Tonga, Fiji, American Samoa and Kiribati. The chair of the Pacific Islands Forum, Tuvalu prime minister Kausea Natano, stressed that people should ignore anti-vax propaganda circulated on social media: “In order to prevent further outbreaks in the region, I want to ask all our Blue Pacific family to heed the advice of your governments and health professionals, and get vaccinated against measles as soon as possible.”

The Covid-19 pandemic will stretch out for months, testing government and community capacity. Under the Coalition, Australia’s aid spending has increased in the Pacific (at the expense of development assistance to Africa and South East Asia). But the shift of resources towards multibillion-dollar infrastructure programs has come at the cost of funding for health services. As Labor’s shadow international development and Pacific minister Pat Conroy has argued, “Total health funding to the Pacific between 2014 and 2018 was cut by 10 per cent. So, while we’re providing some short-term assistance to deal with this crisis, it’s on the back of significant cuts to health assistance to the Pacific.”

Although Labor has been supportive of most government responses to the pandemic, Conroy has been sharply critical of the minister for international development and the Pacific, Alex Hawke: “He’s missing in action in terms of basic provision of public information,” says Conroy. “Minister Hawke is the public face of the government’s Pacific Step-up, and unfortunately he’s in witness protection.”

In the most brutal way, the coronavirus pandemic highlights the reality that the greatest security threat to island nations arises from environmental threats rather than the risk of armed conflict. The Pacific Islands Forum’s 2018 Boe Declaration captured the theme with its call for “an expanded concept of security inclusive of human security, humanitarian assistance, prioritising environmental security, and regional cooperation in building resilience to disasters and climate change.”

Despite Donald Trump’s crude attempt to rebrand Covid-19 as “the Chinese coronavirus,” the pandemic will redefine this regional security debate.

The circulation of misinformation about Covid-19 is yet another challenge throughout the region, given the widespread reliance on Facebook and other social media for news. Pacific media organisations are valiantly trying to support public education efforts while continuing to critique government preparations and messaging.

The same challenge faces the Australian media, which normally reports only briefly on crises in neighbouring Pacific countries, but is now likely to focus even more closely on domestic coverage. This will be exacerbated by the Coalition government’s constant funding cuts to international broadcasting in recent years. Six years ago, Inside Story reported on the gutting of Radio Australia by the Abbott government. The national broadcaster sacked experienced journalists with deep networks in the Pacific and years of experience across the region, then shut a number of foreign-language services. In January 2017, the ABC closed its short-wave broadcasting service — a penny-pinching decision taken without surveys of listeners in Melanesia reliant on short-wave rather than digital broadcasts.

Alongside the billions being allocated to the Covid-19 response in Australia and New Zealand, we could make a vital regional contribution by expanding information services to the region through radio and online. Even as the ABC withdraws its correspondent from Papua New Guinea, the decision to remove geoblocking on ABC iView is a useful step, allowing Pacific islanders to access news and information services. Radio Australia staff have taken great initiatives, such as the new children’s program Pacific Playtime, broadcast across the region every Friday morning to help families in social isolation. More can be done, drawing on the expertise of Pacific journalists on the ground.

Another crucial task is to mobilise and educate faith organisations about the pandemic. Across the Pacific, most people are regular churchgoers (or in Fiji attend church, temple or mosque). The “mainstream” denominations — Catholic, Methodist, Anglican and Lutheran — are now joined by a diverse range of evangelical churches and American-style Pentecostal sects.

This diversity of theological doctrine adds complications to the response to Covid-19 — a problem already seen with the religious response to global warming, the status of women and gay rights. Many people in fundamentalist church congregations have challenged the need for action on climate change, for example, citing biblical injunctions like God’s promise to Noah after the Flood: “Neither will I ever again smite every thing living as I have done” (Genesis 8:21). In contrast, mainstream theologians use the story of Noah and the ark as a parable of the need for preparedness and human agency.

The same debates will play out in coming weeks and months. Some fundamentalists will likely portray Covid-19 as God’s punishment for (add favourite sin here). Other denominations will be more active in responding to the virus. The Pacific Conference of Churches has already invited member churches to limit mass gatherings and change sacraments that involve personal contact or sharing the communion chalice. As one church leader joked, “God will protect us, but He still wants us to wash our hands!”

Meanwhile, the extent of the social and cultural impact is still sinking in. What happens to kava and rugby? How will schoolchildren fare with limited options for online schooling? Will official pronouncements be translated into local languages? How do you keep safe when you can’t afford soap and tissues?

Yet today’s lockdown has parallels with other crises in the region. During the war on Bougainville in the 1990s, life was transformed for people living behind the blockade. The lack of antimalarial drugs and medical care took a heavy toll, tragically undermining maternal and child health. But these years were also marked by innovation and creativity. Cars were kept running using coconut oil instead of petrol, electricity was generated by mini-hydro schemes and biofuels, and imported food was replaced with locally grown, nutritious produce. Courage was displayed by health workers like Sister Ruby Mirinka, who dodged the PNG defence force’s Australian-supplied helicopters and patrol boats to bring medical supplies from the Solomon Islands to Bougainville.

The spirit of self-reliance and confidence forged during those days was reflected last November when 97.3 per cent of the population voted in support of independence for Bougainville. Mirinka served as a member of the Bougainville Referendum Commission that supervised the vote.

As the islands region faces months of uncertainty and anguish, the pandemic will reveal the fault lines — of class, race and gender — evident in every society. But the experience of coming months will also forge a confidence and capacity to tackle other global challenges. There will be no return to business as usual. Around the world, governments are throwing billions of dollars into health and welfare services, transforming jobs and workplaces, discussing nationalisation of essential industries, creating government and industry task forces, and drawing on scientific expertise to guide policy. Isn’t this the way we need to tackle climate change, which the Boe Declaration describes as “the single greatest threat to the livelihoods, security and wellbeing of the peoples of the Pacific”? •

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A few months later, in January, the World Economic Forum’s annual Global Risks Report contained a sentence that should have put most countries into a cold sweat: “no country is fully prepared to handle an epidemic or pandemic.” The source of this declaration was the inaugural Global Health Security Index, released last October by the Nuclear Threat Initiative and Johns Hopkins University.

As it happens, Australia did remarkably well on the index, ranking fourth out of 195 countries. (The United States was ranked first.) But buried in the data was a key reason why Australia has been slow off the mark in dealing with Covid-19: we were weakest in our capacity to respond quickly. The eye-catching number is a zero in the “rapid response” category for “exercising response plans.” This was a failing everywhere, but scoring zero is a real problem — the average was 16.2.

Australia scored zero because we had not completed a biological threat–focused international health regulations exercise, or IHR, with the World Health Organization during the past year. Nor, on the evidence, had we recently undergone a simulation exercise to identify gaps and best practices using an after-action review or a biological threat–focused IHR exercise with WHO.

Put simply, Australia looked good on paper but we hadn’t been practising. We had a 232-page guide, but no apparent worked experience.

A Hansard search of parliamentary records for the words “pandemic” and “coronavirus” produces forty-eight results since 2000, only three of which are earlier than 2020. The most instructive result comes from a Senate estimates hearing in June 2013 featuring Jane Halton, secretary of the Department of Health and Ageing, Chris Baggoley, chief medical officer, and Megan Morris, first assistant secretary of the Office of Health Protection. A question by senator Concetta Fierravanti-Wells elicited an illuminating exchange in which the “novel coronavirus” is described as “very interesting” and “very scary,” followed by a discussion about preparation, including the questions of whether an adequate medical stockpile existed and whether money had been put aside to deal with a pandemic.

The fact that we have never before faced a crisis of this nature doesn’t mean we can’t look to history to offer examples of how we can improve our management. Prime minister Scott Morrison has convened a national cabinet in the style of a war cabinet, and other military-inspired mechanisms can also be used to manage this crisis.

Military forces often put together “red teams” to imitate an enemy and uncover a way to defeat it. As one American military figure puts it, they are viewed “as a bright light we shine on ourselves to expose areas where we can improve effectiveness.” When authorised by the ultimate decision-maker, they provide an independent critique and a counter to groupthink.

Most importantly, they must be set up quickly, not as an afterthought. The British military has a red teaming guide that outlines how it is best done. The Australian Strategic Policy Institute describes how red teaming activities are “purpose built to test and evaluate strategies, policies, frameworks and strategic level plans,” and often involve “stakeholders from across government and external organisations, whether corporate or non-government.” Across sport, politics and business, the process is best known as war gaming.

With federal parliament possibly not sitting until August, it is entirely appropriate for the prime minister to bring the opposition leader into the national cabinet. Another no-regrets decision would be to authorise a red team for Covid-19. This is no drill: we need the very best playbook to defeat the pandemic, and we need to test it fast. Outside public commentary, we need a group the government authorises and expects to shine a light on plans formed by the national cabinet — to challenge, stretch and improve them in real time, in line with the public’s expectations of speed and effectiveness.

An Australian red team for Covid-19 would ensure we constantly test orthodox thinking. It would analyse scenarios to help us get in front of the situation, and diligently prepare the transition back to normalcy once it is under control. Tasks would include: training and deploying surge workforces in health and essential services; addressing an immense debt overhang; restarting and reinvigorating industries sector by sector; getting the workforce back into jobs; institutionalising planning for national disruptions; identifying new expenditures for capacity and capability; and rebuilding local communities so they can better support the most vulnerable.

There is no shortage of names of brilliant and experienced Australians who have worked at the highest level in government, health, the military, industry, business, investment, unions and the community. Some, like former Labor minister Greg Combet and former senior bureaucrat Gordon de Brouwer, have already been enlisted to work on strategies to counter Covid-19. Now is the time to ask a select group to red team our leaders and help their decision-making during our most complex crisis in generations. •

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With things so serious, and changing by the hour, the risk of falling into a gotcha moment is even greater. “But last week you told Australia we wouldn’t be restricting…” says the triumphant interviewer to the struggling politician who, for once, is trying to be honest and not avoid the question.

That’s because this pandemic is different. What politicians think is necessarily changing from day to day, and being responsible leaders they must rapidly adapt. The key to understanding Covid-19 is uncertainty.

The same uncertainty exists among health practitioners. When we try to predict the course of this disease in individuals we have little to go on. Same for the epidemiology. How quickly will it spread? How contagious is it? What measures can reduce the spread and what impact will they have? We can only make semi-informed estimates.

Behind us, we have the experience of the 1918 influenza epidemic, the SARS epidemic and other recent outbreaks, the Middle East respiratory syndrome coronavirus, other respiratory viral illnesses, and the lungs’ generic reaction to insults, known as adult respiratory distress syndrome (ARDS). But this coronavirus is different. So far, the smartest technology has little to offer.

This is where we need to rely on human beings rather than gadgets. Luckily, the international intensive care community has a long history of communicating well with each other through journals, conferences and direct contacts. I receive scores of personal communications every day sharing the experience of colleagues around the world.

We know the coronavirus is extremely contagious and has a higher mortality than normal influenza. It mainly affects adults, and the severe cases are usually among people over the age of seventy and those with chronic health conditions.

This means that normal hospital beds have little or nothing to offer the majority of sufferers — unless it is to enforce isolation, as authorities have done in Singapore. Until the disease progresses, we have no specific treatment; once it does, patients will usually be admitted to an intensive care unit, where the aim is to keep them alive while their bodies mobilise their defences and defeat the virus. Of all the cases of Covid-19 so far, between 5 per cent and 16 per cent have reportedly become serious enough to require admission to an ICU. Those figures are subject to uncertainty, of course, but for planning purposes they give Australian hospitals some indication of the task ahead.

This pandemic has encouraged an even greater sharing of information among intensivists across the world. So far, the information has come mainly from colleagues in China and Italy. As I write, the most cited intensive care journal in the world, Intensive Care Medicine, has just published up-to-date guidelines put together by thirty-six experts based on experience so far. Some of the most helpful information has come from Lombardy, a region in northern Italy. The epidemic has been especially grave in Italy. Intensive care is very well developed there and Milan has been at the forefront of how to treat severe lung disease using optimal artificial ventilation strategies.

Our lungs consist of large and small airways leading to millions of tiny air sacks, or alveoli, where gas exchange occurs. In certain patients, the virus attacks the alveoli. When the body defends itself by mobilising the cells and chemicals that fight the virus, an inflammatory response occurs and fluid pours into the alveoli. This is the same process that occurs in the upper respiratory tract, causing a runny nose; in the case of the alveoli, though, the consequences are far more dangerous. An alveolus full of fluid can’t take up oxygen and excrete carbon dioxide, and so the patient gradually becomes hypoxic, or short of oxygen. Trying to move the heavy lungs up and down, he or she becomes increasingly distressed.

If you are unfortunate enough to be in this situation you will be admitted to hospital and most likely to intensive care. The staff treating you will be dressed in personal protection equipment: a special mask if performing procedures, otherwise an ordinary surgical mask, gloves, gown and a face shield or special goggles. The ICU will be divided into a treating environment, a donning area (for putting equipment on), a doffing area (for taking it off) and a clean support area. Ideally, this will all occur in rooms with negative pressure to keep the pathogens isolated.

The severe bacterial infections common in ICUs often affect many organs in the body, including the heart, kidneys and liver. Circulation to these organs is severely disturbed and blood pressure drops, often requiring complex support for each vital organ. When an infection is accompanied by a decrease in blood pressure and abnormal circulation, it is known as shock, or — in cases where organisms are the cause — septic shock. Coronavirus may be different, with its major impact confined to the lungs, at least in people under fifty. But the data so far is variable, with some reports showing that other organs are affected in up to 35 per cent of patients, depending on their age and chronic health conditions.

ICU treatment can have some influence on the outcome of individual cases of Covid-19, but mortality will be largely determined by a patient’s age and underlying state of health. The first management strategy is to provide more oxygen to patients who are hypoxic. To provide more oxygen and assist breathing, oxygen can be delivered under pressure using specially sealed masks, called non-invasive ventilation, or NIV. This can be done in the emergency department or occasionally in specially configured wards of a general hospital. NIV is often all that is required when the patient is hypoxic.

But most hospitalised patients will rapidly become worse. A plastic tube will need to be placed in the windpipe, or trachea, and connected to a ventilator. To make ventilation more efficient and maximise oxygen delivery, most patients will need to be sedated and have their muscles paralysed. The aim is to maintain the body’s oxygen levels using ventilatory strategies while minimising damage to the lungs. This approach is well known to intensivists.

Of the 1503 patients recently treated in ICUs in Milan, 94 per cent were artificially ventilated and about one-fifth of those had to be “proned.” This involves turning patients onto their stomach, rather than having them sitting up, to improve ventilation and help correct the hypoxia. Of course, caring for patients in that position presents practical difficulties, but well-tried manoeuvres and strategies exist to optimise their care.

Despite optimal artificial ventilation, some patients continue to worsen and become more hypoxic. One more intervention is available: extracorporeal membrane oxygenation, or ECMO. Blood is taken out of the body and artificially oxygenated via a specially designed membrane before being returned to the body. ECMO devices are relatively scarce, and they require a considerable increase in staffing levels and expertise.

Using these approaches, very few Covid-19 patients under the age of fifty will die in the ICU. But what are the challenges for older patients, especially those with existing health problems and those over seventy, who are more likely to become critically ill? So far, regions with heavy caseloads have had to increase their number of ICU beds by moving to operating theatres, recovery areas and other parts of hospitals where the high technology is available. China and Italy have had to rapidly build new areas to accommodate ICU beds, and many countries face shortages of protective clothing, trained staff and ventilators.

With limited resources, will we need to triage patients who are older and already in very poor health, and therefore have a poor prognosis? Intensive care units around the world already do this. If patients near the end of life have little or no chance of recovery, it is generally considered inappropriate to place them on life-support machines.

Maurizio Cecconi, president-elect of the European Society of Intensive Care Medicine and a practising intensivist in Milan, has said that the triaging criteria for admitting patients to intensive care has not so far changed. The data from Milan show that many eighty- and even ninety-year-olds are being managed in ICUs.

But we are faced with the real possibility in Australia of not having enough beds, ventilators, staff and ECMO machines. What happens if a fit and otherwise well thirty-year-old is worsening and no bed or ventilator is available? In normal circumstances, even if my own hospital doesn’t have enough beds we can transfer a person to another hospital. The guidelines from the Australian and New Zealand Intensive Care Society suggest that admission criteria should reflect routine practice, and that similar criteria should apply across all jurisdictions and all patients. Whatever happens, we need to be transparent about the decision-making process and its justification in our dealings with other clinicians, patients and their families.

It is important to be aware that drugs have shown no impact on patients’ outcomes. It is always tempting to hope for a magic bullet, but so far none exists. What we do in intensive care is complex, requiring sophisticated technology, meticulous attention to detail, and team work, especially from nursing staff. It will be a matter of doing what we do every day as well as we can, and we in Australia are in a great position to do this. We are one of the leaders in the specialty of intensive care and provide care equal to or better than any other country. While we are confident that we will provide the best possible care, there is that word again — uncertainty. •

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Even though an HIV test had become available by then, not many people had so far been tested. With no effective treatment available, the prevailing view in the gay community was that it was better just to assume everyone was infected. That had two effects: it meant the responsibility to practise safe sex was shared between everyone, putatively infected or not; and it built solidarity between those becoming sick and those who were still well. For the healthy, it was either just a matter of time until sickness came or “there but for the grace of God go I”; either way, there was no room for judging those with AIDS.

Pandemics seem to have a rhythm. At first, after the alarm is sounded, it all seems far away and implausible. Then comes a phase of downplaying the risk — it won’t come here, it’s not so bad anyway — followed by a polarised debate about whether the official responses are too timid or too extreme (inevitably with economics as much in evidence as health). Then comes a full-on response (and however much we rationalise away the thought “We’re all going to die,” it finds ways of sneaking back). Then there is adjustment, resignation and coping with the new reality. And finally come signs that the worst is over, rarely building to a crescendo but usually to a creeping sense of relief. Perhaps only in retrospect do you realise the burden has been lifted.

In recent days an apocryphal Lenin quote has been doing the rounds: “There are decades where nothing happens; and there are weeks where decades happen.” This has been just such a week, with evidence of the exponential growth in the number of Covid-19 cases in Europe, the Americas and Australia. The core public health goal has coalesced around flattening the curve of the epidemic before health services become overwhelmed.

The most critical piece of information was the public release on 16 March of the Imperial College Covid-19 response team’s modelling of the epidemic impact of Covid-19 in Britain and the United States. It mattered not only because this team is probably the world’s best epidemic modeller, but also because the paper was intelligible as much to policymakers as to epidemiologists (and of course to armchair versions of both).

The modelling suggested that given what was known about the spread of SARS-CoV-2 (the virus name — the disease it causes is Covid-19), letting the epidemic spread with no response would result in 81 per cent of the British and US populations becoming infected, with 510,000 and 2.2 million deaths respectively. Mitigating the epidemic through case isolation, quarantining of affected households, and social distancing of people over seventy would halve the deaths but still result in eight times the current critical care capacity of both countries’ health systems. The only strategy that could keep demand for intensive care beds within capacity would involve suppressing the epidemic through school and university closures, social distancing for the total population, case isolation and household quarantine.

The Imperial College team modelled this approach for a maximum plausible duration of five months, building in an assumption that not everyone would comply. Crucially, the model suggested that the epidemic would rebound after measures were relaxed, to a peak nearly as high as would have been reached without the measures. They concluded that a partial relaxation would need to be mixed with a reinstatement of controls in certain localities as numbers started to rebound. All this is to prevent health system meltdown and buy time until effective treatment or vaccination becomes available.

In Australia, the week saw the progressive alignment of government and public health advice with a suppression strategy. The first signal came from the Australian Health Protection Principal Committee — the federal and state chief medical advisers — whose 17 March statement included a graph showing the daily growth of the epidemic since the one-hundredth case was identified. It showed Australia on exactly the same path as Spain, France and Britain. Clearly, widespread community transmission was on the way, and a significant shutdown would be required.

The data on different national responses to Covid-19 is advancing in tandem with the pandemic. Adding to our sense of the success of the total shutdown in Wuhan and later Hubei Province in China is a growing recognition of the role hospital isolation may have played in curbing the epidemic there. Not only was movement curtailed, but those who tested positive to the disease were hospitalised in the temporary facilities thrown up in a matter of days. This type of isolation could obviously be more stringent than an instruction to isolate at home, and greatly restricted transmission from those with only mild disease.

China has already celebrated the descent from the peak of the epidemic, with zero new domestic infections recorded for the first time on 19 March. But the country is acutely aware of the possibility of epidemic rebound as new cases enter the country. It is too early to declare the complete success of an East Asian containment model, though. South Korea joined China in bending the curve of the epidemic, but has seen something of a resurgence in the past few days. Singapore kept numbers remarkably low but saw a worrying spike in infections on 17 March. Japan’s trajectory has been much flatter than others, but that may reflect low testing rates.

What has become much clearer in the past few weeks has been the extent of “covert” infections — the 60 per cent or so of infected people who have either no noticeable illness or hardly any, but who are likely responsible for the majority of onward transmission. For some, the answer is to test everyone, and the proof is the natural experiment of the town of Vò, where Italy’s first Covid-19 fatality led to the whole population of around 3000 people being tested. All ninety-five cases found and isolated in two rounds of testing recovered fully and new transmission was eliminated within a fortnight. Much as this account is cheering, it will be hard to replicate when it comes to larger and more diffuse population centres. And for the moment, the limiting condition is the availability of tests, with a worldwide shortage of reagents already affecting Australia’s capacity.

The most recent tranche of research funding from the Australian government has been directed at filling some of these gaps. The Peter Doherty Institute at the University of Melbourne is rushing to develop novel testing strategies that promise to greatly reduce the consumables needed. Meanwhile, tests for the antibodies produced by the immune response to exposure to SARS-CoV-2 have also been developed in the past month, and offer two advantages: rapid throughput and their capacity to detect people who have been infected but have recovered and cleared the virus, leaving only the antibodies as evidence of their infection. The latter is especially useful for epidemiologists attempting to gauge the full extent of the epidemic. Sydney company Atomo Diagnostics is hoping to adapt its current HIV self-test machine for Covid-19 antibody testing, a potential development that may have a significant bearing (as its prospectus carefully explains) on its current initial public offering of shares.

The trajectory of HIV testing is instructive. Initially, it was surrounded with caveats and admonitions: pre- and post-test counselling, rights protections, expert administration of the test by doctors and then by nurses. Today, counselling has been dispensed with (there was no evidence it made a difference — all people wanted to know was their test result), rapid HIV antibody tests are cheap (less than 50 cents) and can be administered with a minimum of training, and self-testing with on-the-spot results has proven to be feasible and free of negative consequences. You can order Atomo’s self-test kit online in Australia for $25 (and, in partnership with generics manufacturer Mylan, it is available for a lot less in developing countries).

The twenty-five years it took HIV testing to evolve to this point may be replicated in twenty-five days for SARS-CoV-2. Already, American companies are using ambiguous regulatory flexibility from the Food and Drug Administration to offer a mail-order testing service. Receive the test, mail back the self-administered swab samples, and they’ll text your results within forty-eight hours. Demand seems strong, with one company that offers the test for US$181 advising on its website when daily capacity has been reached.

Testing is at the pointy end of public disquiet concerning equitable responses to the pandemic. The steady drip of announcements of celebrities and politicians testing positive for Covid-19 seems to show that the well connected have no problems getting tested, while most Australians, unless they fit narrow criteria of probable exposure and illness, find themselves turned away. This will likely change, but if we are headed for infection rates of 30 per cent or more of the total population then the queue for testing will stretch out for a long time.

This pandemic strikes at a time when trust in government, social institutions and the media is low. Against this background, public health communication has a herculean task. Unfortunately, the core communication challenges for public health authorities — inconsistency and uncertainty — pull in opposite directions.

The Victorian government did not cover itself in glory when it exempted Crown Casinos from social distancing rules — only revoking this exemption this weekend — or when it failed to call off the Melbourne Grand Prix until the morning the gates opened. All it achieved was a cynical resignation to the notion that money trumps public health. Similarly, schoolteachers are justifiably indignant when social distancing regulations of four square metres for any gathering are manifestly not feasible in classrooms, yet schools are not closed.

Of course, all these decisions are trade-offs between calculations of epidemic spread, economic damage and social psychology. But if health authorities frankly admitted making these trade-offs on an uncertain information base, they would be excoriated for sowing doubt. Australia’s current solution seems to be to seek the maximum possible consistency from the chief medical officer flanked by politicians, and rely on the ABC’s Norman Swan to inject scepticism, confidence intervals and doubt as required.

There’s certainly plenty of uncertainty to go around. Why is the fatality rate in Italy so much higher than in Germany (or China)? Are younger people at significant risk of death, or aren’t they? Do ACE inhibitors for hypertension increase Covid-19 risks or not, and if they do, will the damage caused by people getting off these medications outweigh the potential reduction in Covid-19 risk?

The information is uncertain and the studies are under way, but in the meantime, as technology writer Venkatesh Rao points out, when the narratives desert us, we do the math: “That’s how you know everybody has lost the plot: everybody is tracking the rawest information they have access to, rather than the narrative that most efficiently sustains their reality.”

There can be pleasure in radical uncertainty, of course. It creates a “time out of time,” the numinous experience devoid of everyday calculation, familiar in studies of ecstasy whether religious or secular, sexual or transcendental. But when it is experienced on a mass scale, we fear that anarchy will break out.

The evidence from disaster studies is that chaos may be less likely than we assume. In 2008 the doyen of disaster sociology, Enrico Quarantelli, reviewed half a century of research into responses to catastrophe and disaster to lay bare six myths: that people try to flee in panic, that looting results, that those affected are dazed and passive, that necessary personnel abandon their posts to look after their families, that disasters have severe mental health consequences and that firm top-down control is needed.

Quarantelli found that the evidence, drawn from extensive accounts of a range of catastrophes and disasters, showed the contrary: panic was rare; in the few instances where looting occurred it was not indiscriminate but rather a response to specific pre-existing injustices; immediate and active responses emerged as soon as communities were affected; emergency personnel overwhelmingly played their role even if the needs of their families caused them stress and concern; mental health effects were mild and short-lived (and disasters can even have positive impacts on mental health); and central authorities were the source of most problems in disaster response.

While the media accounts of the aftermath of Hurricane Katrina suggested an outbreak of lawless despair, Quarantelli’s evidence paints a different picture:

What emerged on a massive scale were smaller informal entities and network linkages sometimes but not always anchored in pre-impact known groups. Their pro-social and very functional behaviour dwarfed on a very large scale the antisocial behaviour that also emerged. Improvisation and innovation took place because the everyday traditional routines could not be used or were ineffective in dealing with the problems that had to be addressed.

Crucially, though, disaster studies show these pro-social improvisations emerge when the disruption is perceived as a common threat, not as a conflict. Blame is not just an unproductive pandemic response, it is positively counterproductive. This is why president Emmanuel Macron solemnly declares, “We are at war with an invisible enemy.” Donald Trump has attempted the same pivot, last week characterising himself as a wartime president, but he and his administration seem unable to resist the temptation to blame the “Chinese virus” just like those who persisted in referring to AIDS as “the gay disease” while maintaining they were just “stating the facts.”

So there are choices to be made, and some of them may be good ones. Following the adage of never letting a crisis go to waste, the radical destabilisation in the wake of the onset of the Covid-19 pandemic suggests some solutions to hitherto intractable social problems. The US government found it could create an entitlement to sick leave, the British government has guaranteed lost incomes, and the Australian government boosted assistance to the unemployed (albeit as a one-off rather than an ongoing commitment). In the face of massive shutdown job losses, campaigners for a universal basic income are suddenly finding policy audiences much more receptive.

The extent to which the current crisis results in increased social solidarity and greater equality remains to be seen. The sight of empty supermarket shelves suggests pernicious and competitive individualism has more than a few adherents. But I prefer to have faith in the empirical evidence that ground-up solidarity building will be the predominant response.

The hardest thing to do in a crisis is to maintain a sense of perspective. It is one of the reasons pre-planning happens, which means that Australia’s current template draws on the plans developed to respond to potential pandemic influenza. Last week, as a member of my local hospital board, I participated in a committee meeting by phone in which the senior staff went through the organisation’s contingency plans. It was strangely comforting to hear about the planned responses at different degrees of epidemic escalation and know that for whatever scenario, a scaled response would be put in place. While triage seems an affront in any immediate personal health situation — I must have maximum care right now — it is a daily reality for health services even in the best of times.

The first peak of Covid-19 illness will pass. Rebounds will come. Meanwhile, extraordinary improvisation is happening for the good. The Victorian Infectious Diseases Reference Laboratory has achieved an unprecedented decentralisation of testing facilities down to local level, coming on stream this week. In the world’s densest precinct of biotech innovation, right next to MIT, Moderna’s vaccine candidate based on messenger RNA went into phase 1 human trials on 16 March — an astonishingly fast process using a new, highly designed and yet-to-be-proven way of conceptualising vaccine development. Since February, the Coalition for Epidemic Preparedness Innovations has pumped funding into seven candidate vaccine projects, including one at the University of Queensland. And last Friday the World Health Organization launched SOLIDARITY, a coordinated multi-country trial of four of the most promising treatments for Covid-19.

I don’t know of a similar catalogue of social innovations in response to Covid-19, but it would be good to have one: block by block, city by city they are undoubtedly emerging. I hold out no hope for a deus ex machina. But I do for the cumulative accretion of steps of solidarity, innovation and adaptation. That seems enough to go on with.

Meanwhile, in the service of amassing raw data, what am I reading?

• The World Health Organization’s updates
• Case report updates from Johns Hopkins University and the nifty graphs you can build yourself of selected country trajectories
• The Lancet’s Covid-19 resource centre
• Nature’s coverage
• The International Health Policies Network weekly update
• Somatosphere’s series, Dispatches from the Pandemic
• STAT’s coverage
• The Australian health department website and particularly the Australian Health Protection Principal Committee’s statements. •

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Epidemics of infectious diseases have continued to devastate affected groups in Australia. But these have generally been smaller (and often marginalised) populations, including Aboriginal and Torres Strait Islander people, injecting drug users and gay men. Except for brief periods, such as the early days of the HIV epidemic in the 1980s, mainstream Australia has largely been able to ignore these outbreaks. The viruses we have come to worry most about have been the ones on our computers.

Just like the Australian population, our health system has little experience in dealing with a crisis of this scale. The National Communicable Disease Plan, drawing on experience gathered by the Exercise Cumpston system test in 2006, has assisted in guiding the government’s response. But the realities of responding effectively to the virus have demonstrated the vulnerability of a fragmented, poorly coordinated and inequitable health system. The way it has met (or not met) expectations, so far at least, offers important lessons for our response to similar events in the future.

Health isn’t a solo event

Health policies and programs focus on changing individuals’ behaviour and treating disease and disability. But treating health much more as a team sport will be crucial to successfully combating the coronavirus pandemic. Developing strategies to halt the spread of this virus means thinking not only about how to protect our own health but also about how to work together to minimise its impact on the community.

A commitment to health equity is crucial. Like a soccer team with a poor defence, our abilities are only as good as our weakest players. A stockpile of hand sanitiser in the garage won’t protect you or your family if this means others will expose themselves to infection and become vectors of transmission.

It’s not just about being altruistic (although this is important). When it comes to health even the most selfish among us has an interest in helping others.

This perspective on health isn’t new, of course. It’s more than a decade since the World Health Organization’s Commission on Social Determinants of Health described the vital role in good health played by employment, class, social status, housing and other social factors. A commitment to acting on these issues was recently renewed by the WHO.

Yet, despite a multi-party Senate committee unanimously recommending that the federal government adopt the WHO report, Australia has not acted on any of its recommendations. In fact, some measures of inequity, such as wealth distribution, have worsened: the wealthiest one-fifth of Australians now own nearly two-thirds of all wealth, while the least-wealthy half own less than a fifth. Although there’s said to be “no better place to raise kids,” an estimated 1.1 million Australian children live in poverty.

Despite these inequities, the advice coming from health authorities seems oblivious to the circumstances of many Australians. People are asked to self-quarantine at home; patients arriving at hospitals are told to “return to their cars” and phone for instructions; it’s suggested that we stock up on two weeks’ food. No advice is provided for people who don’t have stable and safe housing, regular employment, a car, a mobile phone, internet access, the capacity to deal with a short-term lack of income, or the ability to purchase and store bulk foods. As lawyer Thalia Anthony points out in relation to prisoners, who are among the most marginalised populations in our community, this failure risks undermining the effectiveness of Australia’s response to the virus.

Fragmentation creates confusion

It goes without saying that viruses don’t respect borders. Cooperation and collaboration between the federal government and the states and territories is essential, but challenging when healthcare responsibilities are split.

For its part, the Commonwealth is responsible for primary healthcare, Medicare, regulation of therapeutic goods (including testing kits and protective equipment), aged care, the medical stockpile, and non-health policies including border control. The states and territories, meanwhile, have primary responsibility for the public hospital system, disease surveillance and quarantine (within their jurisdictions), ambulance services, and most community and social care.

Divided responsibilities inevitably cause gaps, fragmentation and confusion. Getting eight jurisdictions and the Commonwealth to agree on a joint approach can slow the response to a fast-moving and rapidly changing environment. As a 2004 Parliamentary Library research paper observed, “Overlapping Commonwealth/state responsibilities and divisions between clinical health practitioners and public health policymakers were identified as two broad problem areas in Australia’s national arrangements for responding to an infectious disease outbreak.”

During Australia’s response to the epidemic thus far, different governments have provided conflicting advice. People experiencing symptoms have been told to visit their GP, to call (but not visit) their GP, to ring Healthdirect, to self-monitor, or to go to a public hospital for testing. Communication between governments, GPs and hospitals has been inadequate, with GPs receiving inconsistent information about testing protocols and facilities.

“To take one example,” says the president of the Royal Australian College of General Practitioners, Harry Nespolon, “there has been confusion about the type of face masks that GPs need to wear… We are also getting different advice from the states and territories on the tests for coronavirus and who should be taking them — should they be done by a GP in a clinic or should they be done in a hospital in a negative-pressure room?”

This fragmentation is not just a practical problem. It also adds to the confusion and anxiety in the community and reduces trust in governments’ ability to coordinate an effective response to the pandemic.

Coordinated primary care must be a priority

Even if every other part of the health system worked perfectly (which of course they don’t), a primary healthcare sector — GPs and other frontline practitioners — that is under-resourced, poorly coordinated and not always accessible will seriously undermine the effectiveness of our response.

Over the past month it has become clear that Australia’s primary care system is poorly prepared to respond to a major public health threat. This is not the fault of the profession or a reflection on individual doctors and their staff, who are generally highly dedicated professionals doing their best under extremely difficult circumstances. But their efforts have been challenged by a flawed system inadequately resourced by successive governments.

Despite this neglect, governments have counted on GPs to deal with patients concerned about their symptoms or potential exposure, and to provide advice on testing and deal with other enquiries, all on top of their normal workload. Governments’ first advice to people concerned about the virus or experiencing symptoms was to “call your GP,” but their unrealistic expectations of what GPs can and can’t do have exposed the vast gap between the government’s idea of general practice and the reality.

Most GPs are either small businesses or employed by profit-driven companies. They have neither the resources nor the incentive to carry additional capacity — such as quarantine rooms and stockpiles of equipment — to deal with crises. Expecting a local general practice to meet the increased demands for healthcare during a pandemic is like expecting the corner shop to supply everyone’s food and household goods.

“I don’t know of any GP practices that would be capable of testing or seeing a suspected case,” Sydney GP Richard Nguyen told the Guardian earlier this month. “In our practice we have four consulting rooms plus a procedure room. We’d have to dedicate one room as an isolation room. And then you’d have to clean and disinfect the room — logistically it’s just impossible for several reasons, including that we don’t have the physical space.”

In the short term, our primary healthcare system can probably muddle its way through this crisis, largely because of the professionalism and dedication of GPs (and their practice staff). But it won’t be ideal. GPs will take risks, as healthcare workers often do with infectious diseases, and some will undoubtedly get sick. This is not fair to these doctors or to their patients.

Solving this problem means tackling the fragmentation and variability built into the present system and better integrating primary care with other parts of the health system. For years experts and health groups have advocated exactly this kind of reform. The 2009 National Health and Hospitals Reform Commission, for example, called for “strengthened primary health care services” and “the development of Comprehensive Primary Health Care Centres and regional Primary Health Care Organisations… to support service coordination and population health planning.”

Successful examples already exist, including innovative private practices and Aboriginal Community Controlled Health Organisations, and could serve as models for reform. Learning from them and building on the existing (but limited) Primary Healthcare Network infrastructure would strengthen the capacity of the primary healthcare sector to manage future public health threats.

Effective communication is vital

The Communicable Disease Network Australia’s National Framework for Communicable Disease Control was supported by health ministers from all jurisdictions after it was released in 2014. One of its key conclusions was that identifying “a credible and trusted leader” and providing timely, effective and consistent communications were vital during a health emergency.

During this crisis the government has failed to meet this goal in a number of ways. Information has been inconsistent, patchy and sometimes contradictory; key details about the virus and its threat to the community are perceived to have been withheld from the general public; and positions have shifted significantly on some key issues (travel bans, border control, the financial impact of the epidemic) within days and sometimes hours of official announcements.

Political leaders and health authorities have fumbled when answering simple questions and struggled to explain in precise language the reasons for seemingly conflicting advice. When the Council of Australian Governments announced that non-essential gatherings of more than 500 people should be cancelled, the prime minister stated that this did not apply to workplaces, childcare centres, schools, university lectures, public transport, airports “or things of that nature.” The most important messages about behavioural changes required to limit the impact of the epidemic (washing hands, minimising social contact) risked being lost in the confusion.

Efforts by the government to communicate with health professionals have been similarly inadequate. Doctors working at the frontline of the epidemic have described the government’s dealing with them as a “shambles.” The Australian Medical Association has called for authorities to start “singing from the same song sheet” and the Australian Nursing and Midwifery Federation urged the federal government to send “clear and consistent messages to the community in order to contain the rapid spread of the coronavirus (Covid-19) and ease growing anxiety, confusion and concern about this public health emergency.”

Compounding this problem has been the seemingly contradictory behaviour of political leaders. At the same time that the prime minister announced the ban on non-essential gatherings of over 500 people he also said he would be going to a rugby league match. People in hazmat suits cleaned the Parliament House office of home affairs minister Peter Dutton after he tested positive, yet chief medical officer Brendan Murphy said that the prime minister and other cabinet members who had been in contact with Dutton needn’t be tested or self-isolate. Despite the recommendation to adopt social distancing, the PM continued to be seen in close contact with other political leaders, journalists and advisers.

This degree of inconsistency is a serious problem for a government trying to persuade people to change their behaviour in ways that can seriously limit their freedoms. Advice that seems contradictory or frankly impractical (staying 1.5 metres from other people on public transport, for example) or that is not being followed by political leaders themselves undermines the credibility of the message and the authority of the government, and risks people ignoring it altogether.

Of course, communicating in this complex and rapidly evolving situation is challenging. Both under- and overreacting carries significant potential costs. Maintaining a balance between encouraging sensible concern among the community and preventing public hysteria is crucial.

It is understandable that the government focused on avoiding panic. As health promotion expert Daniel Reeders has pointed out, panic encourages a range of ineffective behaviour: it encourages panic buying; it can prevent people from processing what they read or hear, making it much harder to convey accurate information; it puts people in a “me-and-mine first” frame of mind at a time when collective action is required; and it can cause people to dismiss “emotionally dissonant” messages — such as health experts giving calm, measured advice — in favour of hyper-emotive rumours and conspiracy theories.

But it is also important to acknowledge the limitations of the authorities’ knowledge about health threats. As the WHO’s guide to Communicating Risk in Public Health Emergencies puts it, public communications “should include explicit information about uncertainties associated with risks, events and interventions, and indicate what is known and not known at a given time.”

“My biggest concern is people are not talking to their populations like adults,” says the WHO’s Bruce Aylward. “They’re cherry-picking the best possible survival rates [and] outcomes, the lowest possible incidences. You’re just going to compromise confidence of your population.”

These problems are not just a failure of communications but a failure of leadership, which is an essential component of effective risk communication. According to the US Environmental Protection Agency’s Seven Cardinal Rules of Risk Communication, trust and credibility are a spokesperson’s “most precious assets” when communicating risk information. “Long-term judgments of trust and credibility are based largely on actions and performance. Trust and credibility are difficult to obtain. Once lost they are almost impossible to regain.”

This is bad news for a government in Canberra already struggling with criticism over its handling of the recent bushfire season. The trust and credibility that it will lose as a result of its poor response in the early days of the coronavirus pandemic may prove impossible to regain.

Health literacy matters

Part of the communication challenge facing governments is the low level of health literacy in the Australian population. Good health literacy helps people make decisions that maximise their own health and that of others. Poor health literacy makes communicating complex messages and trying to effect behaviour change in a stressful environment even more difficult.

Data on health literacy in Australia isn’t great (which is a problem in itself) but the indications are that it is pretty poor. The most recent national data available from the Australian Bureau of Statistics, which dates from 2006, shows that only 41 per cent of adult Australians were sufficiently literate about health matters to meet the complex demands of everyday life. This rate was even lower for older Australians, with only 28 per cent of people aged sixty to seventy-four considered to have adequate levels of health literacy.

Among the health stakeholders who have recognised this problem is the Australian Commission on Safety and Quality in Health Care. It says that low health literacy can significantly drain human and financial resources and may be associated with extra healthcare costs of 3 to 5 per cent. The problem has been evident in the seemingly irrational response of many in the community to the pandemic, such as avoiding Chinese restaurants.

One of the greatest challenges has been to explain the urgency of slowing the transmission of the virus (or “flattening the curve”), a desired outcome of government policy but a difficult concept to explain.

Also important is health system literacy. When a system is experiencing dramatic increases in demand, it helps if people know where to go for information, advice and care. Talkback radio calls have made it clear that many Australians lack even a basic understanding of our health system. Callers described calling the national Australian Medical Association office for information about where to access telehealth consultations in their local communities, contacting their state health department for information on Medicare-funded services, and being frustrated when their local pharmacies didn’t provide testing services.

The public health system will always bear the burden

Despite the government’s (and the media’s) obsession with private health insurance, this crisis has made clear that it is the public health system we rely on when serious health risks emerge.

The coronavirus pandemic is the greatest health crisis our country has faced for a generation, and private health insurance is basically missing in action. Our annual investment of around $11 billion into this sector does not appear to have strengthened our overall capacity to respond to the pandemic in any respect. At all stages it has been the public health system that has stepped up to manage our response to the virus.

Our public universal insurer, Medicare, is funding bulk-billed and telehealth consultations for people at risk or showing symptoms of coronavirus. Public health microbiology laboratories developed the capability and capacity to detect and confirm cases following publication of the genome sequence for the virus at a publicly funded research institute. In Victoria, testing centres have been established at nineteen hospitals and health services, not one of which is private; nationwide, public hospitals are performing Covid-19 tests as well as treating people who are seriously ill with the virus, all at no out-of-pocket costs to patients.

Far from the “Better Cover, Better Access, Better Care” promised by the private health funds, people with private insurance are being left high and dry by their funds. Anyone who purchased private insurance under the illusion that a policy named “Security” or “Ultimate Health Cover” would be useful in the context of a major health threat would now be experiencing a major reality check.

As one reader of the health policy blog Croakey wrote, “I have maintained private hospital cover for many years because of a suspicion that the Lib-Nats would do away with Medicare if they could. Today I rang the largest, most modern private hospital in Perth and asked what they could do for me if I came down with Covid-19. The answer? Nothing, sorry, you’ll have to go to a public hospital, you can go as a private patient, we don’t have the facilities.”

International experience in responding to the coronavirus pandemic indicates that the countries with strong universal public health systems are having more success than those with a privatised and less equitable approach to healthcare. The message from this pandemic is that private health insurance is (at best) an optional add-on that doesn’t merit the resources it currently receives. If Australians ever needed convincing of the benefits of a strong and well-functioning public health system, this pandemic should be more than sufficient to persuade them. •

Many thanks to Dr Ruth Armstrong for her help with this article.

Jennifer Doggett is Chair of the Australian Healthcare Reform Alliance and an editor of Croakey.

The post Covid-19’s six lessons for Australian healthcare appeared first on Inside Story.

Applying the lessons of the global financial crisis to the coronavirus stimulus package announced by the government this week reveals that we have learned a lot from the past, but we’ve also forgotten a few things.

The first lesson is to diagnose the shock properly. Putting cash in consumers’ pockets works well when the demand for goods and services is flagging. But if the problem is a supply shock — if businesses can’t produce enough because they lack workers or access to their supply chains — then boosting demand ranges from pointless (more customers are of little value if you can’t sell them anything) to counterproductive (the increased demand for a limited supply of goods can force up prices).

The coronavirus is both a demand shock and a supply shock. Consumers are abandoning airlines, shops, restaurants and travel agents at an alarming speed (a demand shock) while many businesses are struggling to source their supplies or to get their workers to come to work (a supply shock).

The government’s $17.6 billion stimulus package should therefore target both households and businesses, which it does. The problem is that most of the package (72 per cent) targets businesses while only a fraction (28 per cent) targets households. This is a gamble. The government is punting on the fact that the virus is much more of a supply shock than a demand shock. Although we don’t yet know the exact nature of this shock, confidence effects and tightening financial conditions in many countries suggest that a lack of demand might now be the dominant force. A more balanced stimulus package would have been prudent.

The second lesson is to target stimulus at the right households and the right businesses. People on lower incomes already struggle to meet basic needs, and are therefore more likely to spend additional money than save it. Stimulus packages that benefit the rich are much less effective than those that target the poor. The government has got this right by targeting income supports at pensioners, social security, veteran and other income support recipients, although the duration of these benefits, discussed below, could be improved.

The same is true for businesses. Qantas, for example, is seeing a big drop in customers. But in recent years, with interest rates and bond yields at historic lows, businesses like Qantas have used their profitability to buy back shares and make record dividend payouts. They have the resources and the borrowing capacity to ride out the shock and are more likely to use government money to buy back shares rather than invest and create jobs.

Business stimulus is best targeted at smaller businesses, which are more likely to suffer cashflow challenges and less able to obtain credit during a shock. The government’s package does well by targeting small and medium businesses. But money will not be enough. The government must focus on keeping supply chains open, particularly through international trade, and ensuring transport and logistical firms keep operating, given their systemic importance across the economy. The slowing in global trade is of huge concern to Australia.

The third lesson is that stimulus needs to be fast. Infrastructure investment can tick both boxes: it boosts demand in the short run when it is being built and boosts supply in the long run through higher productivity. But the time it takes to plan, prepare and build infrastructure makes it a poor candidate for the kind of stimulus we need right now. Some tax measures can suffer the same problem if households and businesses don’t see any benefit for many months and their anticipation effects are small. The government’s significant preference for tax measures over spending measures in the stimulus package could therefore be a problem.

The fourth lesson is that stimulus needs to happen over the right duration. Making some stimulus measures permanent can mean that households and businesses feel no pressure to act immediately, thus defeating their purpose. For this reason, it makes sense for the government’s tax measures to be temporary. But there is no reason to make increases in social security temporary: many of these payments are in dire need of an increase — particularly Newstart, which has remained unchanged for two decades while the age pension has doubled. Given we don’t know how long the recovery will take, now is the time to tackle this long-term challenge.

The sixth lesson is not to fret about budget deficits. The bulk of the government’s revenue comes from personal income and corporate taxes, which fall when economic activity declines. Trying to protect the budget by short-changing fiscal stimulus can be false economy: insufficient stimulus sees a bigger economic downturn and a bigger economic downturn causes a budget deficit anyway by reducing government revenues. Record low interest rates and government bond yields make it an ideal time to increase spending.

Finally, perhaps the biggest lesson from the global financial crisis is that fiscal stimulus should be coordinated across countries. A country’s stimulus can have twice the impact on gross domestic product if it is coordinated with other G20 countries. Why? Some of the increased consumer spending that comes from stimulus is spent on imports from other countries, meaning countries benefit from each other’s stimulus; and increased government spending can lift the value of the local currency at an inopportune time, an effect that is neutralised when countries act together (although with ultra-low interest rates the exchange rate effect is much smaller). Most importantly, my interviews with policymakers showed that countries will launch larger stimulus packages if they are part of a globally agreed effort. At their meeting this weekend G20 officials should prioritise coordinating stimulus and keeping trade and investment flows open.

The government has its work cut out for it. The fact that this is a supply shock as well as a demand shock puts us in uncharted waters compared with 2008. Our historically low interest rates mean that — leaving aside quantitative easing — fiscal policy will have to do more of the heavy lifting. The government’s stimulus package gets many things right, but there is room for improvement. When it comes to fiscal stimulus, the cost of overshooting is far lower than the cost of undershooting. •

The post The hits and misses of the Coalition’s stimulus package appeared first on Inside Story.

In the last few weeks we have found out that Covid-19, a coronavirus with respiratory symptoms similar to SARS, can transmit before symptoms appear, and can be spread even by those who don’t eventually become sick. Luck, it seems, is against us this time.

A generation ago, infectious diseases were a medical backwater. Polio vaccination had been a stunning success: within a year of its licensing in 1955, the first of twenty-five million doses of the Salk vaccine had been produced by the Commonwealth Serum Laboratories and distributed across Australia. That last dreaded childhood disease was virtually eradicated, at least in countries with highly developed health systems. A combination of isolation and increasingly effective treatment also brought tuberculosis under control, and smallpox was well on the way to eradication: denied a home in its human hosts, it soon disappeared, and not even vaccination was needed any more.

The model seemed set. Virologists would get to work identifying viruses, and vaccines would be developed. Viral diseases dependent on human hosts would be pushed to extinction; bacterial diseases would be treated by antibiotics, increasingly powerful as needed, and intensive infection control.

By the late 1970s, modern medicine seemed to have vanquished the age-old threat of infectious disease. Extending these benefits to poorer countries with weak health systems was the only remaining challenge, but this was a task for do-gooder public health and development types, not the core business of high-prestige cutting-edge medicine.

But then, at the beginning of the 1980s, along came AIDS. Medicine was again faced with a disease it couldn’t cure and a pattern of transmission it didn’t understand. Layered on top of the standard waves of fear and stigma — the overblown fears of contagion and the obsessions with “patient zero” and super-spreaders — were fear and discomfort about its first sufferers, gay men, a new and still contested social category.

It didn’t take long, though, for the standard medical playbook to be deployed. AIDS had come to light in June 1981 when a cluster of unusual diseases among young gay men was reported in the US Centers for Disease Control’s Morbidity and Mortality Weekly Report. Less than three years later, in April 1984, US health and human services secretary Margaret Heckler convened a press conference where, alongside virologist Robert Gallo, she announced that the virus responsible for AIDS had been identified and along with it a blood test to “identify AIDS victims with essentially 100 per cent certainty.”

Heckler went on to assert that a vaccine would be developed within two years. Her confidence was misplaced: last month (on 3 February 2020, to be precise) the latest trial of the not-very-promising-but-most-promising-to-date HIV vaccine candidate was called off because infections in the vaccinated group were no lower than in the control group. The most optimistic forecasts for an effective HIV vaccine have now been pushed out to 2030 at the earliest.

With neither vaccine nor effective treatment available, HIV responses had to turn to social means — exposure avoidance, condom use, clean needles. Aided by various forms of denial and “othering,” HIV gradually developed into a full-blown global pandemic. But the effort to find treatments eventually paid off when it was discovered that antivirals that had been relatively ineffective when used alone could work in combinations of two or three. From 1996, effective HIV treatment was rolled out with an immediate impact on death rates.

The old problem of translating medical solutions to resource-poor settings once again reared its head, but this time a concerted global effort extended access even to the poorest countries within a few years. Antiviral treatment, it emerged, could not only stave off disease but also reduce the infectiousness of those with HIV. And when it was taken by uninfected people as prophylaxis, it could also prevent HIV acquisition. These treatment-driven solutions led to a resurgent triumphalism heralding “the end of AIDS.”

Modern medicine again reckoned itself to have won the fight against infectious disease. But it had only a few years to wait before the next potentially global epidemic appeared on the scene.

By February 2003, three months into the SARS epidemic, local health authorities had reported 305 cases and five deaths from atypical pneumonia of unknown cause. Cases spread to Hong Kong, Vietnam, Canada, Singapore and Taiwan. In March, a coronavirus was identified as the probable cause. By the end of that month, countries were considering travel bans. The World Health Organization started recommending against travel to affected areas, although every travel advisory was resisted by the countries named. Singapore and Hong Kong began imposing quarantine measures and closing schools. China’s response was initially slow, with Guangdong officials defensive, and only once SARS reached Beijing in April 2003 did it become a national priority. Full-scale infection control and quarantine measures were put in place and a national mobilisation launched under vice-premier Wu Yi.

As April turned to May, SARS was more or less under control. The last case found in Vietnam was on 7 April, and the WHO removed Vietnam from the list of affected countries on 28 April. By 5 July the last countries with local chains of transmission, Taiwan and China, were finally declared SARS-free.

China, in particular, learnt from SARS, and thoroughly overhauled its infectious disease control measures. The lack of transparency, reluctance to share information, and conflicts between local and central levels were widely perceived as failings, and China decided to transform itself into a paragon of public health virtue in the face of emerging epidemics by valuing shared information, acting decisively and openly, and cooperating globally.

With new diseases now considered inevitable, a new paradigm focusing on health security began to emerge. Zoonoses were the most likely underlying cause — viruses jumping from animals to humans, with bats the most frequent originating culprit, often with an intermediate animal host. Population pressures, with more and more people crowded into newly expanding urban areas, were meanwhile creating susceptible locations for epidemic outbreak.

The 2013–16 West African Ebola epidemic was confirmation of the new paradigm. Previously, Ebola had emerged only in remote villages and seemed to be self-limiting. Because it was extremely infectious via body fluids, came on rapidly, and had visible symptoms and fatality rates between 50 and 90 per cent, an outbreak could be devastating locally but would burn itself out quickly. The 2013 outbreak was the first time Ebola had spread more extensively, into cities, across national borders and potentially across the globe. This epidemic’s almost 29,000 cases were a hundred times the number in previous Ebola outbreaks.

While international support for the affected West African countries was scandalously slow, it came eventually. The “global public good” of international health solidarity became an accepted norm. Health security was one of the few growth areas in Australia’s international development assistance portfolio under the Abbott–Turnbull government.

Contagion and its results: detail from Black Death At Tournai (1349) by Gilles Le Muisit. Bibliothèque Royale De Belgique

Quarantine, isolation and infection control

When the World Health Organization observed that the tools used successfully against SARS dated largely from the nineteenth century, it could equally have nominated the fourteenth century. Separating sick people from healthy ones had been a response to leprosy since biblical times. But it was not until the plague epidemics of the fourteenth century — the Black Death that swept across Europe and the Middle East — that clear notions of contagion and quarantine began to emerge.

When our descendants look back they are likely to place the intellectual culture of Moorish Al-Andalus among humanity’s high points. One of the outstanding figures of the final period of the Nasrid dynasty in Granada was the scholar and poet Ibn al-Khatib. After the devastating plague that struck the city and many others around the Mediterranean in 1348, he produced a short but keenly observed treatise on the Black Death, Muqni’at al-Sā’il ‘an al-Maraḍ al-Hā’il. Based on empirical observation, it included what is arguably medicine’s first precise account of contagion:

It becomes clear to anyone who has diagnosed or treated the disease that most of the individuals who have had contact with a plague victim will die, whereas the man who has had no exposure will remain healthy. A garment or vessel may carry infection into a house; even an earring can prove fatal to the man who has put it in his ear.

This account of contagion could have been put to good use in implementing effective infection control and quarantine measures at the time, but up until the mid nineteenth century the spread of disease was blamed mainly on vague notions of “miasmas” and putrefied air.

Responses to the Black Death did build on the model of sequestrated leper houses, though, and extended it to population movement in general, developing an elaborate codification of quarantine measures. Maritime cities in particular realised they were vulnerable to ship-borne plague.

In 1377 one of the Adriatic’s main maritime powers, Dubrovnik (known as Ragusa in Latin), introduced a requirement that ships from plague-affected areas be held in isolation for thirty days, and travellers from endemic or epidemic zones for forty days (hence the word quarantine) before they could enter the city. Venice, which had ruled Ragusa until 1358, established similar measures, designating a quarantine station on an island near the Lido in 1423, and other Mediterranean cities followed suit.

Even though Ragusa is credited with being the first to introduce a strict quarantine system, it was not completely successful. An outbreak in 1391 prompted even stricter regulations from 1397, but plague recurred in 1400 and again in 1416. When an outbreak in 1422 turned out to be very small, the measures were reckoned to at last be working.

Another wave of intense plague epidemics across Europe and England came in the mid seventeenth century. By now, elaborate public health apparatuses had been set up to respond with quarantine and isolation measures. Systems were particularly well developed in Italy, and the wealth of documentation that survived was mined brilliantly by Italian economic historian Carlo Cipolla. His fine-grained accounts of how cities like Prato, near Florence, responded to plague are uncanny premonitions of Covid-19 lockdowns in Lombardy today; and the anguish of inhabitants forcibly locked into houses and towns with plague sufferers parallels the experience of passengers and crew of the Diamond Princess.

Plague was not the only disease attracting a quarantine response. Syphilis was the “great pox” of the sixteenth century (as opposed to smallpox — “great” and “small” referring to the size of the pockmarks caused, not the severity of the epidemics). Later, cholera, yellow fever, typhoid and tuberculosis (the “white death”) provoked their own regimes of quarantine and isolation.

From the mid nineteenth century, though, quarantine began to lose its primacy, particularly after John Snow famously identified the contaminated pump handle at the centre of the Broad Street cholera outbreak in London in 1852. An understanding of germs, the precise targeting of infection sources, water purification and other sanitary measures, and the increasing use of vaccination proved effective in battling cholera. Quarantine began to be seen as a blunt, outdated instrument.

The disillusion stemmed partly from a conflation of quarantine, isolation and infection control. Isolation of sick patients and thorough disinfection are designed to definitively interrupt disease transmission. Quarantine seems to hold the same promise, but what needs to be understood is that it is fundamentally about probabilities, not absolutes.

The restriction of population movement by quarantine reduces the chances of exposure to the disease. How much it curbs epidemics depends on two things: how well the quarantine is kept, and the characteristic of the disease pathogen itself.

HIV was not a good candidate for quarantine because its years-long incubation period meant its spread was invariably well under way before it became evident. The cooperation of those who might have been exposed was therefore paramount. Stigma and quarantine are always antagonistic, but that didn’t stop a flurry of reactionary activism in 1992 by Bruce Shepherd, head of the Australian Medical Association, who darkly warned that the “gay lobby” had forced aside sensible public health measures. Shepherd was bouncing off remarks by the almost-sainted Fred Hollows that robust public health measures of identification and isolation of gay men were needed to protect Aboriginal communities from HIV.

A few countries tried to deal with AIDS on the model of tuberculosis sanatoria. But even that measure depended on persuading patients to accept a therapeutic embrace rather than be hunted down. That was Sweden’s initial approach, and that of Cuba when it was dealing with HIV in soldiers returning from supporting African liberation wars — the crucial factor being that these were returning heroes, not marginalised outsiders. Cuba has since gravitated to a more orthodox response, supportive and inclusive of gay men and sex workers. Credit for Cuba’s notably lower HIV rates compared with the rest of its region must also go to its highly effective public health system.

Intense focus: Deborah Birx, US coronavirus response coordinator (centre, left), and vice-president Mike Pence after a meeting on the epidemic with Republican senators yesterday. Andrew Harnik/AP Photo

Getting ahead of an epidemic

The lessons of stigma remain pertinent for Covid-19, although it has already become abundantly clear that it is futile to shun at-risk populations. On the contrary, the circumstances of transmission are all too familiar to all of us.

Particularly worrisome is the fact that transmission can readily occur before any signs of illness appear. Last week the Lancet published an account of one such transmission chain. A young woman passed through Wuhan by train on 21 January on the way to visit her family in Nanjing. There, she stayed with her sisters and mother and went to a family dinner on 23 January, before leaving for another city on 24 January. She had no symptoms until fever and a cough set in on 28 January, and she then tested positive to the coronavirus on 29 January. The immediate family with whom she stayed and three of the relatives at the dinner were subsequently found to be infected; two of the relatives at the dinner went to another family dinner the next day and three of the relatives at the latter dinner were diagnosed with the virus within two weeks.

The circumstances described in the Lancet allow for an unusually precise pinpointing of the timing and chain of transmission. But in every other way the report reveals what could well be happening at tens of thousands of family dinners in at least twenty countries.

“Most cases can still be traced to known contacts or clusters of cases,” the World Health Organization’s director-general, Tedros Adhanom, said at his briefing at the end of last week. “We do not see evidence as yet that the virus is spreading freely in communities. As long as that’s the case, we still have a chance of containing this virus, if robust action is taken to detect cases early, isolate and care for patients, and trace contacts.”

It is a universal rule that public health authorities always try to get ahead of epidemics. It is a near-universal fact that they rarely succeed. Covid-19 is still in the balance: the hopeful sign is that reported cases in China have been in steep decline since the end of January; the less hopeful sign is that significant chains of local transmission have erupted in at least twenty other countries.

New epidemics always seem to provide the opportunity to resurface old prejudices. A case in point is the “anonymous doctor” quoted in a slew of newspapers, including Sydney’s Sunday Telegraph, during the first wave of AIDS hysteria in 1982: “Perhaps we’ve needed a situation like this to demonstrate what we’ve known all along: depravity kills.”

Covid-19’s emergence in China just at a moment when the United States is ramping up its propaganda war against its biggest rival gave partisan commentators the opportunity to make outlandish claims about secrecy, cover-ups and the dire consequence of epidemic outbreak under authoritarian regimes. The reverse may well apply. One reason Covid-19 was identified at all is that public health systems with good disease surveillance are able to pick up unusual disease clusters and peer under the surface. More chaotic systems find it harder.

Once again, AIDS tells the story: the only reason AIDS was identified relatively early was because it affected young gay men who were not expected to be falling ill and dying. It depended on gay men as a category visible to the health system, and it depended on their illness being unusual. In fact, an epidemic of “junkie pneumonia” had been picked up in New York at least two years earlier, but deaths among drug users were not unusual, so no alarm bells rang. Similarly, the spread of AIDS in West Africa, predating the identification of the disease in the United States, disappeared into a background of high mortality.

When a schoolboy with no travel history or contact with known cases was diagnosed with Covid-19 in Washington State last week, his virus was genetically linked to that found in a man, recently returned from Wuhan, who had been identified on 19 January. The evidence points to a silent and untracked spread through the community over at least six weeks. The United States may yet prove one of the biggest challenges to the WHO’s hope of tracking and containing the virus.

Donald Trump’s appointment of vice-president Mike Pence to oversee the coronavirus response has been widely criticised, with many pointing to Pence’s dismal record in responding to a 2015 drug-use-driven HIV outbreak in Indiana when he was governor. In other circumstances, designating a vice-president to lead the response would have been taken as a sign of serious political commitment.

Muting the criticism was the swift and savvy appointment of Deborah Birx to the position of coronavirus response coordinator, reporting to Pence. Birx has been the US global AIDS coordinator since 2014, overseeing a US$7 billion annual budget. Her track record has been in classic public health containment and control, with an intense focus on understanding where the epidemic is, and a ruthless determination to spend available resources on targeted, evidence-based responses.

Buying time

New epidemics inevitably carry the burden of fear, prejudice, conspiracy theories and misinformation. But the brute reality of virus spread can be salutary. It creates an evolutionary pressure towards pragmatically effective responses, and heightens the stakes for the sifting of good information from bad.

The current state of play for Covid-19 suggests that China has been successful in containing the first wave of the epidemic in Wuhan and its surrounding province. The extent of asymptomatic transmission suggests that there may be a larger pool of infections than currently estimated, which means that succeeding waves of infection are likely, but may be smaller. It also means that the spread outside China has been extensive, and long chains of transmission seem inevitable in many, if not most, countries. Restrictions on travel, school closures and the cancelling of big public events will reduce transmission, but the challenge will be in balancing costs against benefits.

One implication of a larger-than-estimated pool of infections is that the case fatality rate may be much lower than the current 3.4 per cent figure. The virus may also weaken, and it may eventually be the case that most people with Covid-19 won’t even notice they have had the disease — much as they don’t notice the common coronaviruses that circulate widely and are at most associated with mild colds. But if anything like the current critical-illness rate of 5 per cent persists, then the burden on health systems will be huge.

One reason quarantine measures are still in place despite the evident breadth of spread is that they buy time. The best use of that time is coordinated global action. It is heartening that journals like the Lancet and publishers including Elsevier have established open-access repositories of the latest information.

The development of treatments and vaccines is also proceeding apace. The 2013–16 Ebola outbreak successfully pioneered vaccine trialling in the middle of an ongoing epidemic. Vaccine efforts ramped up quickly during the 2003 SARS epidemic, though unfortunately those efforts faded as the epidemic receded. This time around, vaccine efforts need to kick in as soon as possible — and be pursued until they reach success.

To the extent that the virus is brought under control it will be because of global cooperation, open and accurate communication, and development of widely accessible “public goods,” in this case vaccines and treatments. It seems like we might still need the “global community” after all. •

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This experiment highlighted what behavioural economists and psychologists know all too well: people are awfully bad at assessing and responding to risk. After 9/11, millions of Americans chose to drive to their destinations rather than fly. The result was more than a thousand extra road fatalities, a tragic yet unsurprising outcome given the probability of dying in a car accident is 5263 times greater than dying from terrorism.

People’s innate inability to assess risks is on display again with the coronavirus. As things currently stand, the probability of catching Covid-19 in Australia is statistically indistinguishable from zero. But not only are people already taking elaborate precautions regardless, the precautions they are taking — wearing the same facemask for hours on end and avoiding Chinese restaurants — range from pointless to ludicrous.

This is a big problem for the economy. The World Bank estimates that 90 per cent of the economic damage from pandemics stems from people’s fear of associating with others. Only 10 per cent comes from the virus itself. The core tenet of macroeconomics — “my spending is your income, and your spending is my income” — encapsulates the problem. The Australian economy is losing $1 billion every month by preventing Chinese tourists from entering the country, to say nothing of the even bigger cost of blocking Chinese students, businesspeople and other visitors.

This brings us to the second big cost of the coronavirus: ineffective and counterproductive policy responses. Too many policymakers are prioritising political expediency over effectiveness. Health experts show that temperature checks at airports are a waste of time. Screening for SARS in Canada in 2003, for example, found zero instances of the disease, despite its killing 774 people, including forty-four in Canada. Yet many policymakers have been quick to implement this measure.

In Laos, the government has put a price ceiling on face masks, fearing that poor people will not be able to afford them. Putting aside the limitations of face masks, the embarrassingly obvious result of this policy is textbook economics: a chronic shortage of face masks.

In China, the government has been busted lying to its citizens, suppressing information and covering up its failures, all of which have made the spread of the virus deadlier.

Australians in China were allowed to come home while Chinese students studying in Australia have been barred, despite both groups carrying the exact same risk. The travel ban on people from China and Iran has similarly not been replicated for Italy, Korea or Japan, despite some of those countries having higher rates of infection. And the government’s claim that hospitals can rely on their “surge capacity” has left many doctors and nurses searching high and low for where this alleged capacity is hidden.

What should the policy response be? Economics has some answers.

Eradicating pandemics is what economists call a “weakest-link public good.” It is a public good because nobody can be excluded from enjoying this benefit, regardless of what country he or she lives in, and one person’s enjoyment of a pandemic-free environment does not stop another person from enjoying the same thing. But it is a weakest-link public good because it depends on the weakest link in the chain. Germany and France can completely eradicate the virus, but if Italy drops the ball, it will be back within days.

Supplying a weakest-link public good requires global cooperation. It requires rich countries with strong healthcare systems to help poor countries with weak healthcare systems. The coronavirus has now emerged in more than sixty countries and has been confirmed in some of the world’s poorest, including those in sub-Saharan Africa. But the bilateral and multilateral cooperation that allowed the world to eradicate smallpox is conspicuously absent. Australia should be helping our neighbours to defeat the virus by sending money, supplies and medical professionals, not randomly blocking some people over others.

Economics is fundamentally about incentives, as is any effective response to the coronavirus. People’s incentives need to be aligned with the social objective. People who don’t have adequate paid sick leave have an incentive to go to work and infect others. People who don’t have medical insurance (many Americans, that is) have an incentive not to seek treatment. And people who feel like they are being abandoned by the system have little incentive to adhere to the system’s quarantines and curfews. If economics shows us anything, it’s that incentives matter.

At the macro level, the economic impact of the coronavirus could be substantial. Friday’s 3.3 per cent fall in the ASX200 is a confronting risk assessment from markets. If the coronavirus is as easy to spread and as dangerous as the 1957 Asian flu, it could kill fourteen million people and wipe $500 billion off global GDP, according to analysis by ANU’s Warwick McKibbin and Alexandra Sidorenko. They find that the cost to Australian GDP could range from 0.80 per cent (the mild scenario) to 2.35 per cent (the moderate scenario), 5.58 per cent (the severe scenario) or 10.58 per cent (the ultra scenario). The severity is driven by how households, firms and governments respond. Given the Australian economy is starting from a weak base, even the mild scenario would halve Australia’s current year-to-year GDP growth (and this is before the weak March quarter is considered).

The Morrison government is getting ahead of the curve by announcing a willingness to implement “targeted, modest and scalable” fiscal stimulus. The Reserve Bank has similarly expressed concern, although its forecast of a 0.2 per cent hit to GDP growth in early February now seems optimistic. If the US Federal Reserve cuts interest rates, which markets are pricing at a 90 per cent probability, the Aussie dollar will appreciate, putting more pressure on our Reserve Bank to cut rates and move closer to quantitative easing. Markets are putting the chances of a rate cut from the RBA at 18 per cent for March and 68 per cent for April.

The problem is that macroeconomic stimulus — whether it’s fiscal stimulus or monetary stimulus — works well for demand-side shocks (where consumers stop spending) but less well for supply-side shocks (where business supply chains, investment and production come under pressure). The coronavirus is both, but the supply-side impacts of the virus mean that the benefits of stimulus will be more limited. Increased consumer demand is of limited value when firms can’t access their supply chains. This means that governments must be proactive in keeping markets open and helping businesses weather the storm.

The ultimate economic cost of the coronavirus is unknown. But what we do know is that the bulk of the cost will come from how consumers and governments respond, underscoring the importance of a measured, science-based approach. If panic and political expediency are prioritised over policy effectiveness, the treatment will be worse than the disease. •

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Cheery patriotism, benign internationalism, girl talent, radiant humour, sheer pizzazz: it’s all here. Lines from a world away ping in my ear: “The vale of tears is powerless before you… / Monsters of the year / go blank, are scattered back.”

That was back in January 2019, at a small railway station north of Tokyo. Local primary school students’ classroom posters for the city’s 2020 Olympics, fifty in all, had — for a few days only, it turned out — taken the place of advertising boards. Pure chance had put me there, and no doubt the discovery’s random and fleeting nature was part of the delight. Now, thirteen months on, as the Olympics inch towards the finishing line — warily eyeing the coronavirus’s spurt in the outside lane — that Miyahara hour feels as distant as the moon.

In part, that’s because a year ago the Olympics (here, the term embraces the Paralympics) were still more background hum than daily buzz. The transition to a new imperial era and the detention of Nissan-Renault executive Carlos Ghosn led the news, while the big sporting fixture on the horizon was rugby’s world cup. Even broadcaster NHK’s latest year-long Sunday night historical drama, Idaten, lacked sparkle. With the ageless Takeshi Kitano as a comic-monologue rakugoka, the series told Japan’s Olympics story from 1908 to Tokyo’s hosting in 1964. Artistic flaws, premature scheduling and the chilly media landscape for national broadcasters may have contributed, but lowish ratings also hinted that the public would catch up with the Olympics at its own pace.

With this new year’s diary switch, the Games of the XXXII Olympiad (24 July–9 August) and the XVI Paralympic Games (25 August–6 September) appeared in plain sight. A wealth of trimmings — days-to-go countdowns, transport ads, hi-tech promotions, festivals, merchandise, books — was making them inescapable. A December poll asking “Is it good for Japan to host the Olympics?” found 86 per cent said yes, 12 per cent no. The most popular reason was “a good opportunity to show Japanese culture to the world.” Tokyo 2020 was nearing the last lap in some comfort.

At that very point came a pebble in the shoe. The circulating respiratory disease 2019-nCoV, at first a down-page story, hit home on 20 January, when the imminent (and routinely welcome) arrival of thousands of Chinese tourists on their new year holiday became mixed with alarm that some high-spenders might prove virus-spreaders. A Japanese coach driver and guide tested positive, as did scores of international cruise-ship passengers quarantined at Yokohama, three elderly Japanese among them dying after disembarkation. Face masks and hand sanitisers sold out. Inevitably, the Olympics entered the frame. Yoshirō Mori, octogenarian head of Japan’s Olympics Committee, gave faltering assurances that the games would go ahead, but virology professor Hitoshi Oshitani and other Japanese specialists are wary.

The first Japanese death, of a posthumously diagnosed woman in her eighties east of Tokyo, came on 13 February. It had no obvious link to Wuhan. This was a second turning point. A recent vogue word, feizu (phase) — as in atarashii (new) feizu or feizu ga kawatta (the phase has changed) — was much used, soon followed by kurasutā (cluster). The mainland incidence of the renamed Covid-19 grew daily, reaching 146 on 25 February (with another 691 on the stricken ship).

Nerves, rightly, are jangling at the prospect of Tokyo 2020 being overtaken on the home stretch. But brains are also in overdrive managing the parallel tests of containing the virus and keeping the Olympics show on the road. Japan’s spring rituals are cutting back: the Emperor’s open day on 23 February, the annual Tokyo marathon on 1 March, school graduations, companies’ welcome to fresh recruits. And more dates are crowding in.

The torch relay of Japan’s forty-seven prefectures starts on 26 March in Fukushima, site of the nuclear meltdown on 11 March 2011 (or “3.11”). Public commemorations of that day’s triple disaster in the Tōhoku region (earthquake, tsunami, nuclear), which took 18,000 lives, will also shrink, as will remembrances of Tokyo’s sarin gas attack on 20 March 1995, which killed thirteen people. Pre-Olympic training and publicity events are thinning (or, for volunteers, going online) and the sense of diminishment is widespread. Abreast of the Olympics, yes, but primarily alert to the lung-attacking illness, Japan’s public is in a very different situation from even a month ago.

For as long as the virus flourishes, the games’ destiny is on hold. Turning back, even scaling down, looks unthinkable given the funds, deals, careers and reputations at stake. It would not be Japan’s decision alone, or even mainly. Covid-19 is mandating big transnational call-offs too: flights, conventions, Formula One. If the Olympics must go because of a worldwide health emergency, they will.

In aggregate, the incipient pandemic and sporting extravaganza presage a global moment. Covid-19 already serves as another topical lesson in the current human system’s fragility, and in the Olympics’ habit of crystallising global uncertainties even as they seek to dissolve them. Even that might not earn the International Olympic Committee, or IOC, overdue scrutiny. But Tokyo 2020 and Japan’s authorities, which own the Olympics’ share of Covid-19’s fallout, can’t long avoid the glare.

At the time of writing, the official Olympics line is unchanged. News and sports bulletins still hug their own track. A Japanese cabinet office poll on 17 February found 36 per cent saying the government is handling the crisis well, 52 per cent not. The government’s latest draft policy, announced on 25 February, focuses on keeping serious cases to a minimum, reducing social mixing and then, as needed, “asking the public to stay indoors.”

Covid-19 aside, insofar as that is possible, a just-completed stay in and around Tokyo has given me an insight into the efficacy of the plans made and messages honed since the 2013 bid was won. That bid, in turn, drew inspiration from Tokyo 1964. Tokyo 2020’s use of these two legacies is also in play now — and even perhaps its link to a third, 1940’s phantom games. That said, the supremely ambitious “recovery Olympics,” its motto “united by emotion,” will not easily be given up. The rest of this article touches on four of the many local aspects of this approaching world story: Tokyo 2020’s concept, locations, hazards and 1964 prototype.

Until Covid-19 hit, Tokyo 2020 had come almost unscathed through its seven-year gestation. There had been bumps on the road, and to say these didn’t deflect progress would only be half true. The other half is that the project raced ahead of them, its eyes on a prize outranking even the games themselves: Japan’s regeneration. The twin affective levers of this strategic purpose were the host city’s magnetism and that clever promotional tag on the 2013 bid: the “recovery and reconstruction Olympics” (soon, the first term was deemed to be enough).

Embedded in the notion was a subtle linkage of domestic and international audiences. The 3.11 tragedy, two years before, was still prominent in the nation’s psyche, while in many international minds it was recalled less for its dreadful images and heartbreaking stories than for the well-reported fortitude and dignity of survivors.

In this context, “recovery” gave Tokyo’s impressive sales pitch — and then its delivery plans — a quintuple kick. It deployed global admiration for Japanese kizuna (solidarity) and energetic voluntarism in the 3.11 aftermath. It positioned the Olympics as a means both to enhance Japan’s global standing and to inject prosperity — largely via tourism — into the country’s less favoured regions, notably Tōhoku itself. It mustered to the cause the omotenashi (hospitality) awaiting visitors. It readied Japan’s domestic sectors, and citizens for the challenges to come.

And the fifth ingredient: it displayed Japan as, in effect, twice over a phoenix nation. Just as Tokyo 1964 was intended to mark a turn from post-1945 pains towards modernisation and international respectability, Tokyo 2020 would be a route from 3.11’s destruction towards a more dynamic economy and a confident, outward-looking country. A parable of redemption from ruination thus bound the two events and eras.

That uplifting story looks most credible in two parts of Tokyo: the Kasumigaoka area of Shinjuku, where a new national stadium designed by architect Kengo Kuma has replaced the 1964 one on the same site, and the giant stepping stones of reclaimed land towards Odaiba, where athletics, tennis and swimming complexes are levers of an even more comprehensive project set to pull this vast city’s centre of gravity to the southeast.

Walking from Sendagaya station in mid January, an early glimpse of Kuma’s feat is the unobtrusive fit of his bowl with its environment. Closer up, a tiered mesh of walkways, timber pillars and greenery brings home his “living tree” designation. Across the road, a new Olympics museum bustles with active seniors and junior high students on school trips. More gather for group photos in the landscaped area outside, whose installations — a popular replica of the Olympic rings, the 1964 cauldron, and statues of the educator-athlete Kanō Jigorō, an Idaten hero, and Pierre de Coubertin, founder of the modern Olympic movement — are a model of spatial-social awareness.

Kanō Jigorō watching over Kengo Kuma’s Olympic stadium. David Hayes

The stadium area is rich in associations with the Meiji era (1868–1912), and nearby gardens, galleries and shrines give it a stately air. By contrast, to walk from glitzy Ginza over the Sumida River’s Kachidoki Bridge and onto Harumi Island — with its construction sites and towering new blocks, huge trucks thundering past on the gaping expressway — is to touch the future (ten minutes after the phrase hit, I disquietingly spotted it on a come-to-buy sign). An immense sky, rare from ground level inside Tokyo’s urban maze, enhances the sense of virgin territory, as does the surrounding water. Ginza, thirty minutes to the north, is already way past.

On Toyosu Island a hi-tech wholesale food market, relocated from creaking Tsukiji in late 2018 after a bitter wrangle, now keeps the tourist and business clocks in more equable sync. Ariake brings the Olympics into fuller view, its gleaming hotels, shopping malls, parks and railway stations as much a showcase as its sports facilities. Tokyo’s southeast flatlands were (like Ginza itself, and Asakusa and Taitō) once synonymous with the pungent culture of the shitamachi (low-lying tenement districts) that made the city’s wares, saw to its daily needs and kept it entertained. That phase in the city’s history is over, its legacy now most palpable in booming nostalgia for the Shōwa era (1926–89).

This airport-strip-like series of artificial islands ends at Odaiba, once fortified to deter any foreign incursion after Commodore Perry’s “black ships” probed Edo (later Tokyo) Bay in 1853–54. An observation deck is well placed to scan the official Olympic rings, which were hauled offshore by a barge on 17 January, as well as the athletes’ village on Toyosu (destined to become apartments), Tokyo’s glittering night skyline and, in the early morning — a kindly guard assures me on a grey afternoon — a beautiful view of Fujisan.

Throngs of amiable international tourists, mostly Chinese, were busily recording the sights, particularly Gundam, a giant humanoid robot. It was a foretaste of peak Tokyo during the northern hemisphere’s high summer. Two days later the Asahi Shimbun was reporting that an “old-fashioned confectionery shop” in the mountain resort of Hakone had already banned Chinese nationals from entering.

That day, the breathtaking scale and detail of Tokyo’s groundwork exuded promise of a mega-event that could well equal Sydney’s and London’s instant acclaim. Yet there was never, on either side of Covid-19, any guarantee of a smooth Olympics landing.

For one thing, the trek has been bumpy, even by host cities’ usual standards. The late architect Zaha Hadid’s florid stadium proposal was annulled in favour of local hero Kuma, to a many-sided uproar in the profession. (“The government is skilfully manipulating the public’s xenophobia,” said Arata Isozaki, who had nonetheless called Hadid’s design “a turtle waiting for Japan to sink so that it can swim away.”) An emblem design was replaced after plagiarism charges. Japan’s previous Olympic Committee president resigned over vote-buying. The ticket lottery and volunteer systems were skewed. Mounting costs fuelled regional ire over Japan’s Tokyo-centricity.

Tokyo’s Odaiba precinct. David Hayes

The IOC, like FIFA and other sporting hegemons an unaccountable nexus of commercial and political power, floats above all this: secure in its lucrative commercial deals, outsourcing of costs to the host, exclusion of local businesses from the jamboree, and covetous ticket allocations to members, family and cronies. On the big picture, the University of Lausanne’s Emmanuel Bayle, writing in 2019, is lethally restrained:

[There] are still no real international checks and balances on the governance of the IOC or the [International Sports Federations] within an Olympic System that now includes numerous stakeholders. Given the growing financial importance of the Olympic phenomenon and the Olympic Games, improper conduct, including poor governance, corruption, worship of mammon, doping and the use of sport to further geopolitical or economic aims, has the potential to severely damage the reputations of the IOC and organisations belonging to the Olympic System.

For another thing, these base mishaps and lockdowns join a high gambit shared by the IOC and Japan long before Covid-19 was heard of: the very decision to hold the Olympics and Paralympics in the country’s hot and humid summer, which is also its usual typhoon season. The 1964 games took place in October, safely beyond (as it happened) a torrid summer of water shortages. Today, American NBA and European soccer schedules, holy to sponsors and broadcasters, make such a diary shift unthinkable.

One peril of the wager is a repeat of October’s immense Reiwa 1 East Japan Typhoon, or Hagibis, the fourth such calamity in Japan since July 2018. Such typhoons’ increasing frequency and power is leading to “a major shift in Japan’s disaster policy,” says Koji Ikeuchi, Tokyo University professor of civil engineering and expert in water-related disasters. Hagibis forced the cancellation of three matches in rugby’s world cup, which pales against the ninety-eight deaths it inflicted, although the competition, spread nationwide to droves of enthused niwaka (overnight fans), absorbed the damage with an uplifting mix of brio and respect for the victims.

The same university’s Earthquake Research Institute works on the basis of a 70 to 80 per cent probability of a mega-quake by 2050 in the Nankai Trough, a Pacific Ocean trench under much of southern Japan. Tokyo itself may be more resilient than in 1923, its plans to cope elaborate, but its vulnerabilities — including its below-sea-level southeast’s exposure to storm surges — are a fact. The inner earth sends frequent reminders. The effects even of Ibaraki’s magnitude 4.8 quake at 2am on 1 February shook this non-tyro foreigner. “The ground is adjusting,” said one of my Japanese family, lightly, in the morning.

A dispute over health pressures on endurance athletes pushed the IOC, to its credit, to transfer marathon and race-walking events to Sapporo, the main city of Hokkaido on Japan’s northern island. There, July temperatures are on average five to six degrees cooler than Tokyo’s. “A painful decision, not an agreement,” protested Yuriko Koike, Tokyo’s mayor. This climate-related concession leaves the outdoor program more than usually exposed to extreme heat and humidity.

Japan’s national tourist association expects forty million visitors in Tokyo’s greater metropolitan area during the events. Measures to alleviate any discomfort include free ice cream, artificial snow (the real thing is getting scarcer), heat-blocking road surfaces, and shade trees. The IOC entourage might not need those: its Tokyo base is — where else? — Ginza’s Imperial Hotel.

For all these hurdles and pitfalls, opposition has been relatively muted. A spate of books in 2013–16 assailed the choice of Tokyo, and anti-Olympics pressure groups such as Hangorin no Kai (No Olympics 2020) sprang into life. Resisting the inevitable became harder as the post-Rio juggernaut got into gear and prime minister Shinzō Abe’s Liberal Democratic Party cruised towards its third landslide in five years. But critics such as the indefatigable sports journalist Gentaro Taniguchi — whose new book says the Olympics “are at the mercy of commercialism and nationalism” — and the tabloid Nikkan Gendai newspaper continue to carry a dissident torch.

Tokyo 2020’s confidence, meanwhile, grew with each passing hitch. At its core is that parable of rebirth from rubble, a chain that goes beyond 3.11 to Tokyo 1964 — a future-oriented event that was only later seen in cyclical relation to Tokyo 1945 and the terrible fire-bombing that razed it and dozens more Japanese cities.

From the start, Japan’s second summer games have drawn heavily on the moral capital and potent symbolism of the first. The latter’s five-year run-up was politically febrile, but Tokyo 1964 turned out to be a landmark in the nation’s history. What made it so, above all, was that an unrepeatable psychic and experiential mix brought Japanese people, collectively and in their individual millions, to an (albeit complex) emotional release.

Such is the kernel of a tremendous NHK documentary, the fifteenth in its A Century in Moving Images series. Its archive footage of Tokyo’s pre-Olympics mania of demolition and construction depicts the capital as reeking, jammed, litter-strewn — and parched. Four months before the games, only 2.2 per cent of Tokyoites named them as a top priority, while 59.2 per cent said other issues (above all, a water shortage) were more important. With two days to go, the heavens burst: a cleansing typhoon.

Optimism took flight with sporting success, Japan’s sixteen golds earning third place in the medals table. Further buoyancy came from displays of popular enthusiasm, from avid crowds on the torch and marathon routes to the finale’s unexpected happy chaos. Athletes mingled and hearts melted to a mass chorus of the school graduation tear-jerker “Hotaru no Hikari” (“Light of Fireflies”), Japan’s emperor doffing his hat when a Kiwi athlete blew him a kiss.

The imprint of Japan’s 1937–45 wars is everywhere in the NHK series, as a marker of closeness and distance alike. Yoshinori Sakai, born in Hiroshima prefecture ninety minutes after the atomic bombing, lit the Olympic flame in 1964. Tadashi Matsudaira, engineer on the Tokyo–Osaka (Tōkaidō) Shinkansen, launched days before the games began, had worked on the navy’s wartime Zero attack planes. The novelist Sonoko Sugimoto, aged eighteen, heard prime minister Hideki Tojo address a mass rally of conscripted students on the same stadium site in 1943. (“Today is also connected to the past. I feel fearful of that fact.”) Hirobumi Daimatsu, oni (demon) coach of the women’s volleyballers who won gold against the Soviet Union, had survived the 1944 battle of Kohima; he played driving father to the textile factory team, several of whom had grown up without one, and later go-between.

Many intellectuals, including Yukio Mishima and Yasushi Inoue, were moved by the Olympics experience. (Kodansha’s instant collection of writers’ responses was republished in 2014.) The novelist Hitomi Yamaguchi, who saw in the marathon a spirit of human fellowship, had another epiphany when the hinomaru (national flag) was hoisted after Japan’s great hope Kōkichi Tsuburaya took bronze in the race. “For the first time since the war I could see the flag raised without any dejection. With no hesitation, a good feeling. Tsuburaya-kun, arigato!”

But Tokyo’s frenzied makeover, with its many ravages, led Akiyukii Nosaka and Takeshi Kaikō (Kaikō Ken) to ambiguous self-reflection. Only now that old neighbourhoods are gone, and links to a discreditable past broken — wrote Nosaka, with a hint here of his own — is it possible to look back without shame: a “half improvement.” Kaikō’s year-long reports for Asahi Weekly, often featuring the low-paid, insecure workers sweating to finish behemoths on time, concluded with one titled “Sayonara, Tokyo.” A fragmented city had become a mirror of his own anguish: “Walking around Tokyo, the more I knew the less I could understand. Just asking continually is the only answer — that’s all I can say.”

Tokyo 1964’s great dramas and intense emotions, understandably shorn of complexity, define its place in public memory. For 3.11, the agony of human loss and destruction does the same. Tokyo 2020 seeks to honour the two moments, in the latter case with gestures of symbolic inclusion at every stage during the games and by delivering promised reconstruction afterwards.

Astute as the prospectus is, its tone can’t help but imply that Tokyo 2020, even before it has happened, transcends these unique and dreadful precedents (and not only because it comes later). Its driving aim sounds assimilative, its wreckage-to-riches tale prescriptive, its insistent amity cloying. Its very seamlessness recalls the critic Jun Etō’s take on postwar censorship under American occupation: “a closed linguistic space.” There is a lack of humility. In the apt Irish phrase, Tokyo 2020 has lost the run of itself.

Tokyo 2020’s slick fusion of utility and piety has always left room for a scepticism that — like the many waterways buried in concrete by the first Olympics — runs deeper than mere opposition. In Kōtō-ku library, above a room lovingly devoted to film director (and local boy) Yasujirō Ozu, I came across a rich photographic record of 1964 in Tokyo, published in December by the Japan Press Research Institute and Kyodo News. The editor’s then-and-now reflection is pointed, even moving (and the last word, having come to it independently days earlier, was stunning to read):

The Japanese people [in 1964] were overwhelmed by the competition from foreign athletes. They had a feeling of yearning and a renewed sense of patriotism, while suffering from an inferiority complex about their backwardness… [Japan on the eve of 2020] is becoming more confident of its national power and sports. But Japan has lost a sense of freshness, dedication and humility.

More sweeping is the verdict of an acquaintance, a civil engineer in his fifties, who in lucidly cynical English cites a litany of reasons why Japan “has no need” for the Olympics now. As we talk in Ōmiya’s beautiful new public library, across the border in Saitama prefecture, T-san holds responsible a government with “no strategy, direction, vision,” and an “anachronistic” education system that holds young people back. The accursed games are, in this view, the epitome of a wider national and civic malaise.

Such bleakness could turn out to be justified without being vindicated. John Rennie Short skewers the IOC cohort’s fourfold “event capture” (infrastructural, financial, legal, political) that traps hosts even as they promise their citizens a new dawn. The post-Olympics backlash tends to take hold a year later, as debts mount, scams leak and memories fade. Its own passing can, in some cases, rekindle the original glow. Tokyo 1964’s homegrown hangover included a spate of bankruptcies, political imbroglios and environmental scandals. Yet its reputation soars above them. Tokyo 2020 could, assuming it delivers the initial goods, extend the pattern. The Olympic dream machine grinds facts, and critics to dust.

More immediately for Tokyo 2020, everything depends on Covid-19’s course. Nothing is foreordained — or foreclosed. The soon-to-be-pandemic, expanding in Iran, Italy and South Korea, continues to reset plans and minds in Japan. One plausible scenario is that a call-off becomes imperative as grim diagnostics rally an international bandwagon of competitors. Another, were a path to the games to be cleared, is that Tokyo 2020 audaciously enfolds the virus’s retreat into the “recovery Olympics” tale. A third, darker vista was seeded prior to the infection’s surge, in a tech store I visited where licensed Olympics merchandise adjoined disaster prevention goods. If they were to overlap during the games, Tokyo 2020’s mighty edifice would not escape the damage.

If it is to be the first, quick is best. If the third, preparing and praying will have to do. For everyone’s sake, sportspeople and worldwide niwaka foremost, the second must be devoutly hoped for. Let it be a great Olympics — and the last in this form. Neither Japan nor anyone else should indulge the IOC and its kind any longer. Once, under the station rafters, Miyahara’s elementary school students “put paid to fate, it abdicates.” Now, monsters of the year are regrouping. Those who would be on the angels’ side need seriously to raise their own game. •

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In key respects, though, the reality of life in the United States no longer matches the reputation. In some respects, the country has become less dynamic than several of its peers and the living conditions of its people nearer the middle rank, or worse, among affluent democracies.

One sign of this shift comes from the Human Development Index, which was created by the UN Development Programme to measure not just economic wealth but also the broader wellbeing of national populations. The HDI measures three central dimensions of human development — longevity, education and material comfort — on a decimal scale, with 0 as the lowest score and 1 the highest. In 2015 the highest-ranking countries were Norway, on 0.949, and Australia and Switzerland, both on 0.939.

Figures for 1900 are from United Nations Statistical Yearbook 1955. (The Netherlands figure is for 1910.) Figures for 1950 from United Nations World Population Prospects, 1996 revision. Figures for 2000 from US Census Bureau International Data Base. Data for 2015 is from Pensions at a Glance, OECD, 2017, and G20 data.

Especially revealing is the annual rate of change over the quarter-century from 1990 to 2015. Among eighteen comparable democracies, the United States had the slowest increase, just 0.27, compared with a mean of 0.49. As a result, it was overtaken by several other countries and slipped from second to tenth place.

A key reason for this relatively poor performance was an only modest improvement in life expectancy among Americans. Life expectancy lifted dramatically in the eighteen countries during the twentieth century, and was still improving in the first decade and a half of the twenty-first century. By 2015, the figures for the eighteen countries were closely grouped around 81.7 years. The highest was Japan and the lowest was the United States, the only country to record a figure below 80. Its rise was also the lowest during that period — 1.7 years compared with a mean of 3.4.

Worse was to come. In each of the next three years life expectancy in the United States actually fell. The decreases were small — totalling 0.3 years between 2014 and 2017 — and a rash of possible explanations has been offered, including opioid addiction, suicide, the cost of healthcare, rising rates of obesity and economic hardship. It may also have been a temporary blip, but it is a clear turnaround from a long period of growth.

Not entirely coincidentally, the United States is also the most unequal of the eighteen democracies by far. Several democracies became less equal over the past quarter-century, reversing the trend in the decades after the second world war.

Inequality may also be contributing to the United States’s consistently mediocre performance in the OECD’s Programme for International Student Assessment, or PISA, tests. Held every three years since 2000, PISA examines fifteen-year-old students on maths, science and literacy skills. Conducted in seventy-two countries in 2015, the scores were scaled so that the mean for the thirty-five OECD member countries was 500. American schoolchildren averaged below 500 in all three domains, but were particularly poor at maths, scoring just 470, a distant last among the eighteen most comparable democracies.

The United States is still among the world leaders in research and development, with high scores on innovation and a record of adopting emerging technologies early. But inequality is pertinent here, too. Although the country played a central role in the development of the internet, for example, the proportion of the population who were internet users in 2016 was the second-lowest among the eighteen countries, ahead only of Italy. No other country among the eighteen had a higher proportion of households without broadband.

Alongside these objective measures, a nunber of subjective indicators suggest a growing alienation. Apart from Italy, American citizens had the least confidence in the legal system — 43 per cent — among the eighteen nationalities, compared with Australia’s 58 per cent, an eighteen-country mean of 64 per cent, and Denmark, Norway and Switzerland all scoring above 80 per cent. The figures for the United States and Italy also declined more sharply over a decade in which many countries showed increased confidence.

Source: Government at a Glance, OECD, 2017

Americans were also unusually suspicious of the media. Trust was greatest in Finland (62 per cent), the eighteen-country mean was 45 per cent and Australia came in at 42 per cent, but the United States languished at 38 per cent. It also recorded the highest proportion of citizens (31 per cent, compared to an eighteen-country mean of 17 per cent) who say they have been exposed to “fake news.”

None of this portends dramatic collapse, and several other areas testify to the continuing strength of the United States. But a combination of stagnation in certain areas long presumed to be improving, worsening inequality becoming more socially dysfunctional, and increased political alienation suggests a malaise that will challenge whoever wins in November. •

All the data in this article comes from How America Compares, published last month by Springer. The book also features detailed data across many other areas.

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The fact that the government was able to misuse these two programs so easily raises questions about other health-related funding decisions.

Health spending ranges from targeted, small-scale grants to multibillion-dollar national programs. Over the past two weeks alone, health minister Greg Hunt has made six significant funding announcements, including $22.3 million for “new treatments and breakthrough cures,” $5.5 million for ten new medical research projects, $32 million for partnerships between industry and researchers, an unspecified amount for additions to the list of subsidised pharmaceuticals, and the provision of free glucose monitoring devices for 21,000 people with diabetes (as part of a broader $300 million program). Two weeks earlier the prime minister had announced $76 million in new funding to support the mental health needs of people affected by the bushfires, including grants targeting affected communities.

Given what we know about the sports rorts controversy, can we be confident that these decisions were made without reference to political advantage? After all, Senator McKenzie is not the first politician to be accused of pork-barrelling: previous federal governments have come under scrutiny for issuing additional MRI licences in marginal electorates, for example, or, more famously, promising funds to keep Tasmania’s Mersey Hospital open despite expert advice to the contrary.

Funding decisions targeted at marginal seats are easy to spot. But politics has triumphed over policy in many other cases, including in some of the largest healthcare programs. They go unnoticed partly because of the size and complexity of the programs, which makes it difficult to identify when and why crucial decisions are made. But the lack of recognition also shows how the disproportionate influence of interest groups is seen as a routine component of policy development rather than an intentional strategy to advance certain interests over those of Australian consumers.

Take, for example, one of Australia’s biggest health programs, the Pharmaceutical Benefits Scheme, or PBS. Considering the scheme represents around 15 per cent of the health budget, or just under $13 billion in 2019–20, it’s reassuring to know that decisions about which medicines to subsidise are based on expert advice from the Pharmaceutical Benefits Advisory Committee, or PBAC, and subcommittees made up of clinicians, health economists, consumers and other stakeholders.

There’s a problem, though. The committee might be independent, but it is purely advisory. Final decisions are made by the health minister or (if the medicine is likely to cost more than $20 million a year) federal cabinet.

This discretion provides a window of opportunity for companies and professional groups that want to influence listing and pricing decisions. It’s hard to say how often they succeed, but we do know that (at the very least) pharmaceutical companies invest substantial resources in attempting to influence PBS decisions, in many cases funding consumer organisations and “experts” to advocate on their behalf. The evidence that drug prices on the PBS are higher overall than in comparable countries suggests that this investment might be paying off.

Can the politicisation of the PBS be reduced? Lobbying in general, including by pharmaceutical companies, could be made more transparent by applying the same standards to all people seeking to influence government, whether they are “in house” (which currently exempts them from the lobbying register) or external. The drug testing that companies plan to use in applications for PBS listing could be pre-registered to strengthen the evidence base for decisions. More effective procurement mechanisms for medicines — competitive tendering, for example, as in New Zealand — could be adopted. And local prices could be benchmarked against international prices.

Each of these safeguards has already been proposed without success. Increasing the transparency and objectivity of the PBS process can be difficult when both government and the pharmaceutical sector benefit from its politicisation — pharmaceutical companies because they can use their influence to have their products listed or their prices raised, governments because listing new medicines provides a steady stream of positive media opportunities.

Medicare is another major area of health spending (around $23 billion in 2018–19) in which the evidence suggests political interests influence funding decisions. The implementation of recommendations of the MBS Review Taskforce is a good example. The taskforce was established after health economist Adam Elshaug and his colleagues identified more than 150 potentially low-value procedures on the Medicare Benefits Schedule, or MBS. Among them were knee arthroscopies and spinal fusions (in specific circumstances) that carried significant risks for patients and were backed by little or no evidence.

Of the almost 6000 items on the MBS, Elshaug found, only around 3 per cent had been formally assessed against contemporary evidence of safety, effectiveness and cost-effectiveness. Many of these items were listed some time ago and, until recently, there had been no systematic process for updating listings in line with new research and changes in clinical practice.

Despite the fact that the taskforce’s seventy committees have made extensive recommendations in sixty-seven reports since work began in 2015, the number of low-value procedures on the schedule has not fallen significantly.

Not surprisingly, medical groups have lobbied hard. Anaesthetists, for example, objected to changes that would have reduced rebates for their services in line with evidence that the current arrangements don’t represent good value. GPs objected when one of the review committees recommended more Medicare funding for nurse practitioner services. Clinical psychologists objected to a proposal to remove the differential rebates between services provided by clinical and non-clinical psychologists.

The government has been reluctant to risk political damage from conflict with the medical profession, particularly since the health minister has worked hard to re-establish the Coalition’s credibility in his portfolio after Labor’s 2016 “Mediscare” campaign and public relations mistakes by previous ministers.

Medical groups know that the Coalition can’t afford a public battle, and they have used this fact to their advantage by lobbying against changes that might reduce the earning potential of some of their members. As a result, much low-value care continues to be funded through Medicare and consumers continue to receive treatment that exposes them to risk but delivers little or no benefit.

As is the case with PBS listings, identifying the exact processes of influence is difficult. Given the fate of many of the MBS Review Taskforce’s recommendations, though, it appears that interest groups have been successful in persuading the government to let political considerations override the benefits of making evidence-based changes.

One of the most politicised areas of health funding is the private health insurance rebate, a scheme that costs taxpayers around $6 billion in direct subsidies and a further $6 billion mainly in revenue lost via tax breaks for higher earners. This adds up to around 120 times the funding that went into the controversial Community Sports Infrastructure Program grants and yet, despite frequent calls for a review, the scheme has never been evaluated against its aims.

The private insurance rebate is an example of how an ostensibly universal program can have a different impact on different communities, depending on their political colour. Because membership of private funds varies significantly across regions, the allocation of funding under this scheme differs according to a community’s political affiliation.

Put simply, Coalition voters are much more likely to take out private health insurance than people who support Labor or the Greens. In fact, the market research company Roy Morgan found in 2016 that twenty-one out of the twenty-five electorates with the highest level of private health insurance membership were Coalition-held.

Four years on, this situation has barely changed — although two of the Coalition seats have changed hands, one to an independent (Warringah) and one to Labor (Hindmarsh). Even so, the ten electorates with the highest level of private health insurance membership are all still Coalition seats and, overall, three-quarters of the top twenty-five electorates are represented by Coalition MPs.

This means that the private health rebate goes disproportionately to areas represented by Coalition members. While all taxpayers contribute to the subsidies via their taxes, areas with a greater proportion of Coalition voters receive significantly more benefits. Without any overt political agenda, the rebate can therefore be a highly effective way of directing public funding into areas with a specific political allegiance.

A much more equitable use of this funding would be to redirect the $12 billion towards services — public hospitals, public dental services and allied health services — that benefit the whole community. This would also be a much more efficient use of resources.

Yet another big spending area within the health portfolio is the Community Pharmacy Agreement, or CPA, a deal between the federal government and the Pharmacy Guild that sets remuneration levels for the dispensing of medicines and funds home medicine reviews and other pharmacy-related programs. The current PGA, the sixth, includes around $19 billion of funding over five years; the next one (currently being developed) is reported to include around $25 billion.

The potential for improper influence in the CPA largely comes from the lack of transparency in its development and execution. Negotiations involve only limited input from consumers, other peak pharmacy groups and other key stakeholders, obscuring whether the agreement’s remuneration levels represent good value for the Australian community and whether all the conditions outlined in the agreement have been met.

The Australian National Audit Office shares these concerns. In its report on the administration of the Fifth Community Pharmacy Agreement, it found that

shortcomings in Health’s performance reporting and 5CPA [Fifth Community Pharmacy Agreement] evaluation framework mean that the department is not well positioned to assess whether the Commonwealth is receiving value for money from the agreement overall, or performance against its six principles and objectives…

and

there is no ready basis for the Parliament or other stakeholders to determine the actual cost of pharmacy remuneration delivered under the 5CPA.

In this environment, the Pharmacy Guild can promote its own interests at the expense of the community. Extensive evidence suggests this has occurred over a series of CPAs, resulting in anti-competitive practices, higher prices and reduced access for consumers.

Unlike in the case of the sports rorts affair, though, the findings of the auditor-general (and other similar reviews and inquiries) have resulted in very little negative publicity for the responsible minister or the government. In fact, Greg Hunt is currently negotiating a seventh CPA with the Pharmacy Guild that will lock in another multibillion-dollar agreement for the next five years.

Of course, interest groups can only exert power over governments to the extent that governments allow themselves to be influenced. A crucial enabling factor in all of these examples is the willingness of governments of all persuasions to trade off good policy outcomes for short-term political gains, even when independent, evidence-based processes are in place (the PBS), or the evidence suggests that funding mechanisms and processes serve the interests of specific groups at the expense of the general community (the PGA).

The problem could be at least partly solved by reducing the government’s role in health funding decisions, while still allowing it to set broad policy directions and respond to emerging health threats. This could be done in a number of ways.

First, a new independent body could take on many of the decisions currently made by government. Labor’s pre-election proposal for an independent body to administer health funding is worth considering, although it would need to be given final responsibility for at least some health funding decisions and not just function in an advisory capacity.

Second, mechanisms for giving consumers input into health resource allocation decisions should be used throughout the health system. A number of existing models, such as citizens’ juries, have been used successfully in Australia for this purpose. They can tackle inequities in our current system by bringing in groups usually under-represented in health decision-making, including Aboriginal and Torres Strait Islanders, people with chronic and complex conditions, people with lived experience of mental illness and people from rural areas.

Third, Primary Healthcare Networks, Aboriginal Medical Centres and other community-based health organisations could be given a greater role in resource allocation. These organisations have transparent governance processes and consumer/community representation, and are far removed from the day-to-day pressures of federal politics. They also know their communities’ needs far better than ministers and bureaucrats in Canberra. Both Britain and New Zealand have decentralised significant components of health funding and offer important lessons for Australia.

Any of these options would help depoliticise the health system and reduce the influence of a small number of interest groups. They could also tackle the perennial underfunding of preventive health measures and take account of the social determinants of health and the health impacts of climate change.

Even with these changes, though, governments could continue to make health policy and funding decisions that deliver political benefits at the expense of the wider community. Given that both sides of politics have a vested interest in maintaining the status quo, supporting free and independent reporting on healthcare decision-making should also be a high priority. •

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Presenting the report to parliament yesterday, prime minister Scott Morrison described it as a “stark and sobering” tale of “hope, frustration and disappointment.” He said something very similar last year, calling out the failure of the current approach and the hubris of those who had created it.

Yet the past year has not only seen problems go unresolved, it has also seen considerable progress in some areas — and enough of each to generate both scepticism and optimism.

The basis of the optimism is the December 2018 commitment by the Council of Australian Governments, or COAG, to partner with Indigenous people in refreshing the Closing the Gap framework and creating a forum for ongoing engagement. The formal partnership agreement between COAG and the National Coalition of Aboriginal and Torres Strait Islander Peak Organisations (Coalition of Peaks) came into effect in March last year.

Since then, a series of community consultations has considered how this new partnership might work. In January, the Coalition of Peaks released its Community Engagement Snapshots report, which found strong support for the three reform priorities it had proposed: developing formal partnerships between government and Aboriginal and Torres Strait Islander people to close the gap, boosting community-controlled services, and improving mainstream service delivery. A fourth reform priority — local data projects led by local communities and organisations — will be sent to COAG.

The Indigenous leaders engaged in this process are feeling optimistic that a full partnership approach can show the way forward. But their view is offset by the prime minister’s refusal to commit to an Indigenous recognition referendum until “there is consensus,” a position at odds with his commitment to the beginning of a “new era.” It will be hard for Indigenous people to trust the government to deliver a new approach when it consistently sidelines the work of the Referendum Council and the central importance of the Uluru Statement from the Heart.

How can Closing the Gap be improved? Fully recognising that their validity is limited by my non-Indigenous status and a lack of formal consultation, these are a few thoughts.

In policy terms, the focus must be on the key underlying causes of disadvantage.

First, racism. The lack of progress on this key determinant of the physical and mental health of Indigenous Australians may explain part of the unremitting gap in health and socioeconomic outcomes. Tackling and reducing racism, including ensuring that healthcare is culturally safe and respectful, should be an integral part of policies and interventions aimed at improving Indigenous health, especially that of children.

Second, very high rates of Indigenous incarceration are, in the words of a recent PwC report, “unfair, unsafe and unaffordable.” Inappropriate imprisonment and the failure to ensure needed post-release services lead to loss of culture, identity and connection to the land, aggravating the cycle of disadvantage and poverty. A new justice target is part of the refresh of the Closing the Gap framework, but if it is to be effective then the courts, police, corrections services and social services will all need to adopt its principles.

Third, safe and secure housing is key to the health, wellbeing, safety and dignity of Indigenous Australians. A new report from the Australian Institute of Health and Welfare found that in 2016, 29 per cent of Indigenous Australians were living in a dwelling with major structural problems, with 15 per cent of households lacking at least one basic facility (a functioning kitchen, bathroom, laundry or toilet). The proportions are higher in remote areas.

In focusing on these three areas, the government must commit to a real and enduring partnership with Aboriginal and Torres Strait Islander communities and organisations. Despite the rhetoric, the Morrison government’s commitment to consultation has generally been deficient.

Not long after the last election, the prime minister announced a new National Indigenous Australians Agency within his own department. Indigenous affairs minister Ken Wyatt described it as a “new era of co-design and partnership,” but the decision was made without consulting Indigenous groups. Meanwhile, the National Congress of Australia’s First Peoples lost its funding and the government persisted with its expansion of the cashless welfare card in Indigenous communities.

The decision to double down on the cashless card came despite growing evidence that it is adversely affecting many lives, has failed to get users into jobs, and is opposed in many communities. Many people subject to the card feel they have been punished by a loss of control over their own finances. This blanket imposition of a political ideology backed by very little evidence is completely counter to a partnership approach.

Another consultation-free act was the axing of funding for the secretariat that oversees the thirteen-member National Family Violence Prevention and Legal Services Forum. This annual $244,000, a tiny outlay for government, was justified by reference to an independent evaluation that, on the contrary, recommended increased resourcing.

And on the day Scott Morrison was promising a new approach to Closing the Gap, it was rumoured that the government had taken a unilateral decision to end funding of Indigenous housing — a dismayingly plausible possibility that highlights how little attention is paid to the social determinants of health.

These various government decisions also highlight the lack of coordination across departments and agencies. When prime minister Tony Abbott moved responsibility for the majority of Indigenous programs to the prime minister’s department in 2014, under the rubric of the Indigenous Advancement Strategy, the shocking news that he also cut more than $500 million from the programs hid the fact that the move might facilitate a whole-of-government approach to tackling Indigenous problems.

That has never come to pass — and it still doesn’t happen even within portfolios. Hearing loss, trachoma and rheumatic heart disease, for instance, all involve a similar healthcare approach (cleanliness) for prevention, yet these conditions continue to be tackled under a series of separate programs. Their high incidence in Indigenous communities won’t be reduced without a coordinated effort to improve housing.

“Every minister in my government is a minister for Indigenous Australians,” the prime minister declared yesterday. Given the known occasions on which the real Indigenous affairs minister, Ken Wyatt, has been sidelined (the referendum, for instance), Indigenous communities will need some convincing on this point.

They will also be looking for evidence that programs are introduced — and evaluated — where they are needed. Here, the signs haven’t been good. A June 2019 report from the Australian National Audit Office identified delays in evaluating the five-year-old Indigenous Advancement Strategy. The prime minister’s department had not met guidelines, the report said, and nor had the department kept records of key decisions or set targets for all programs and projects.

In October 2019, the new National Indigenous Australians Agency released an equally, if not more, damning report on the past ten years of Closing the Gap. (Oddly, the date on the report is March 2018, more than a year before the agency was established.) Among its findings were three fundamental criticisms. Cultural determinants are not captured in the policy framework, which makes collaborating with Indigenous Australians difficult. The evidence base to support many programs is lacking or weak, and programs are rarely evaluated. And the effort to close the gap has been hampered by inconsistent political leadership, constantly changing policies, insufficient resources, and workforce and funding cuts.

Finally, the funding maze needs to be streamlined and made more transparent. Organisations and communities deal with a level of complexity and “red tape” that would never be tolerated by the general business community, with the evidence suggesting that some Aboriginal health services are juggling forty or more funding sources with separate application and reporting requirements. Too often communities are unaware of services for which they are eligible.

A 2016 study identified 1082 separate Indigenous-specific programs. Less than one in ten had been evaluated, and most have produced little evidence of effectiveness. Multiple service providers often compete in the same communities (assuming there are providers), and duplication and waste are rife.

The impact of funding conditions on the governance and performance of Indigenous organisations is under-researched. Evidence suggests that the public financing of Indigenous organisations is successful when the focus is on the organisation rather than the program. Funded organisations should always be required to be accountable to their constituents; performance indicators should be negotiated rather than imposed; achievements should be rewarded.

Encouragingly, the health department will introduce a new funding model for the Indigenous Australians’ Health Program’s primary healthcare program in July this year. Three-year funding agreements, annually indexed, will become the norm, and the administrative burden will be reduced.

Recent efforts by the Productivity Commission have gone some way to tackling the lack of transparency. Preparing an analysis for Oxfam in 2017, I found it very difficult to track spending on Indigenous programs on the basis of publicly available data. But I did find every indication that the government is increasingly looking to mainstream services and programs to meet Indigenous people’s needs, especially in non-remote areas. While 55 per cent of the programs funded under the Indigenous Advancement Strategy were run by Aboriginal and Torres Strait Islander organisations, 81 per cent of direct Indigenous expenditure went towards mainstream services.

Pat Turner, lead convenor of the Coalition of Peaks, has described the gap between Indigenous and non-Indigenous Australians as “a gaping wound on the soul of our nation.” This wound won’t be healed without the best efforts of all Australians. The prime minister is right to say that the Closing the Gap strategy has reinforced “the language of failing and falling short” and neglected to “celebrate the strengths, achievements and aspirations of Indigenous people.”

Refreshing the program must involve building on the expertise and wisdom of Indigenous individuals and communities and the abundant success stories that have largely been unrecognised and uncelebrated. The Oxfam report In Good Hands: The People and Communities Behind Aboriginal-led Solutions is just one of the many excellent places to start. •

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Government is about steeling the leadership for the crisis that can suddenly rain down from a clear blue sky. And of those unexpected events, two are particularly fearsome: food safety scares, and public health emergencies.

Chaos in Hong Kong can be blamed on meddling foreigners. The same goes for economic woes. Faithless officials take the rap for everyday mishaps and misdemeanours. But with potential health emergencies, the buck stops at the top.

The contaminated milk crisis in 2007, before the Beijing Olympics, raised fundamental questions about whether the party was up to the job. Although heads rolled at senior levels, a legacy of distrust persists to this day: even now, most milk powder is imported. The SARS outbreak in 2002–03 saw the country locked down, and officials felled, before the party’s chief troubleshooter at the time, Wang Qishan, came to take charge. SARS was contained, and the lessons learned are no doubt being deployed now by party leaders.

The social contract is simple. Yes, Chinese citizens put up with a repressive, undemocratic form of governance. Yes, they have to suffer the sometimes-brutal impact of authoritarian rule. Yes, many are aware of how their news is censored and their freedoms curtailed: after all, 140 million Chinese travelled abroad last year and know a bit about what the outside world is like. And, despite the online restrictions, 900 million have a good idea of what happens in the outside world via the internet.

Most believe that the controls have one justification: the ability of the party to supply stability and predictability, especially during an emergency. Even when they are suffering one or other of the many indignities inflicted on them by the agents of the state, Chinese people can console themselves with the thought that China’s system is geared, better than any other, to deal with challenges like the coronavirus.

So far, with a swiftness democracies are assumed to be incapable of, Xi’s administration has implemented measures to contain and combat the disease. Wuhan and another fifteen or more cities have been closed off from the outside world. A 1000-bed hospital has been built in a week. Rumours and claimed misinformation spreading via the internet have been quashed. Resources have been deployed speedily to where they are needed. By the end of January, in important ways, the country had come to a standstill.

And yet habits die hard. Despite the fact that it is doing a far better job than it did during the SARS outbreak, trust in what the government says is low. People have taken refuge in their homes as much out of scepticism about the government’s response as in response to official edicts. The centralised decision-making structure has demonstrated its inherent inflexibility, with five million having taken the opportunity to leave Wuhan before a curfew was put in place. Then there are the bureaucratic headaches that never seem to cease in China: permits much delayed for a plane-load of British nationals scheduled to leave the city on 29 January, for instance.

Some things can’t be blamed on the government. There is a nasty strain of schadenfreude in some of the Western media coverage. In some cases, it seems to almost gleefully equate the virus with China’s growing power and international heft. Despite the fact that the number of people who have contracted the disease is still very small, Chinese abroad have reported being treated in discriminatory ways. Whatever faults Beijing may have, though, it has probably done as well as any government would in dealing with a wholly new disease, and one that appears to manifest symptoms only after some days’ delay.

Even so, it is politics, not just containing the pandemic, that matters for Xi. He has created an aura of invincibility, laying claim to constructing the most disciplined, focused political and administrative machine in the world. It is precisely on the basis of a need to handle crises like this that his project is justified. This is the first major test of his leadership, and his response is being watched with acute interest.

Much depends on the next few days and weeks. If the government is able to contain and then eradicate the disease, a rich political harvest awaits. It will have shown the world that the system it has created can do what it is meant to do — deal with big problems that need to be sorted out urgently. The party leadership will maintain its mantle as supreme crisis managers.

If things go awry, and the disease gets out of control, then both the human and the political costs will be horrible. The party’s image will be shattered. Even the most hardened opponent of Xi and the organisation he leads would have to admit that a situation like this, potentially triggering the government’s downfall, would not be a price remotely worth paying.

Everyone has to hope that China’s autocratic government is able to enforce its edicts and eradicate the coronavirus. If not, we face the dreadful possibility of a pandemic spreading through China and beyond. That would be a disaster not just for the party and not just for the Chinese people, but also for the world. •

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The most dangerous component of bushfire smoke are tiny particulates, no more than 2.5 micrometres in diameter, known as PM_2.5. Over the past twenty years, studies have shown that high levels of PM_2.5 have contributed to millions of premature deaths in highly polluted cities like Beijing and Delhi. Sydney, Canberra and other Australian cities have recently joined this list. In 2016 alone, exposure to PM_2.5 contributed to an estimated 4.1 million deaths worldwide from heart disease, stroke, lung cancer, chronic lung disease and respiratory infections.

Even before the current cataclysm, air pollution was a major health hazard. While Sydney’s prevailing average of 6 micrograms per cubic metre (6 μ_g/m³) is within international health standards, it is above the levels observed in most European and American cities. A study led by the Sydney Public Health Observatory’s Richard Broome estimated that particulates and associated forms of pollution already account for between 310 and 540 premature deaths annually.

As far as can be determined, the mortality and health risks of PM_2.5 are a linear function of the level of exposure. Being exposed to 6 μ_g/m³ every day for a year, for example, amounts to 2190 “microgram days.” Broome and his colleagues’ work implies that each microgram day is associated with between 0.14 and 0.25 premature deaths. This figure is consistent with a range of international studies they cite.

The overall mortality effects are also a linear function of the number of people exposed. That’s why a city like Delhi, with thirty million people and an average PM_2.5 of 150 μ_g/m³, suffers tens of thousands of premature deaths every year.

Since the start of the bushfire emergency, particulate levels have been far above the historical average, reaching an extreme of 250 μ_g/m³ in Oakdale, ninety kilometres from central Sydney, on 10 December. According to recording stations in Sydney, the average for November and December was 27 μ_g/m³, more than four times the usual level. That implies somewhere between 160 and 300 additional premature deaths.

But the fires began earlier than November, and Sydney is not the only city they have affected. Many millions of Australians have experienced the impact of the fires, and there is no reason to expect the emergency to end any time soon. It’s quite likely that the total number of premature deaths will be more than a thousand, and possibly more than the 1300 deaths expected on our roads (some of these, tragically, caused by the fires).

Climatic oscillations such as the Indian Ocean Dipole, which have contributed to the severity of the current disaster, are expected to abate over time, so it’s probable that we won’t see a similar disaster next year, and perhaps for a few years to come. But the underlying trend of global heating that made this season so catastrophic isn’t going away. Next time the oscillations are unfavourable, further heating will make things even worse.

Our current approach to dealing with climatic disasters, developed during the twentieth century, doesn’t deal adequately with steadily deteriorating climatic conditions. At a minimum, we need a standing national body, with substantial resources, ready to respond to such disasters as they occur. This would almost certainly wipe out the Morrison government’s treasured surplus, which is why the resistance to any kind of action has been so vigorous.

Even worse than budget fetishism has been the cultural commitment of the government to climate denialism and do-nothingism. The right’s commentariat peddles anti-science nonsense on a par with anti-vaxxerism and flat-earth cosmology, eagerly lapped up by the mostly elderly readership of the conservative press. The government can’t endorse this nonsense officially, so it takes refuge in the idea that Australia accounts for only a small proportion of total emissions (on their dubious accounting, 1 per cent).

But even 1 per cent of the current catastrophe is still a disaster. And just as emissions in other countries contribute to disasters here, our 1 per cent plays its part in fires, floods and other climate-related disasters around the world. No matter how you do your accounting, Australian climate denialism is already costing hundreds of lives, with much worse to come.

We might hope that the scenes we have witnessed would shock our political class out of its torpor. So far, there is little sign of that happening. •

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Based on private insurers’ performance to date, their proposal this week to cover primary care and specialist “in-room” services would increase consumers’ out-of-pocket expenses, increase the proportion of gross domestic product consumed by healthcare, and reduce the system’s overall equity and efficiency.

The private heath funds argue that adding out-of-hospital services to their offering would have one key benefit: it would reduce premiums. The current system, they say, creates a perverse incentive for relatively straightforward procedures to be performed in expensive hospital settings. Under their plan, more of these could be carried out in the community.

It’s certainly true that a more seamless approach to funding would direct resources towards the most efficient healthcare setting, taking into account the needs of the individual consumer. When the current system was developed the boundary between hospitals and other health services was more sharply drawn; new treatments and technologies have blurred that boundary, and an increasing range of procedures are performed more cheaply and more conveniently outside hospitals.

But there’s no evidence that the private funds could finance out-of-hospital services more efficiently, or do it in the best interests of consumers. In fact, the data we do have, both locally and from overseas, shows that private health insurance is an inefficient way of funding healthcare. Countries with no universal coverage and a larger private health insurance industry spend more overall on healthcare without improving health outcomes.

The stand-out example, of course, is the United States, where around 35 per cent of health funding comes from private insurers and an enormous 17 per cent of GDP is spent on health. Yet health outcomes are poorer than in many other lower-spending countries, including Australia.

There’s no doubt that the countries with the most efficient healthcare systems — those that spend less and deliver more — are those that offer universal coverage financed mainly from public sources. Private health funds, on the other hand, have no ability to control the main outlays in the healthcare system — doctors’ fees and hospital charges — which are the major drivers of healthcare costs. The inability of the private funds to control fees is evident in the inappropriately high bills being charged by some specialists. It’s no coincidence that general practice — the one speciality area that private funds can’t cover — is relatively free of complaints about outrageous fees.

Private insurance is also more likely than Medicare to lead to overtreatment. This is no small problem: in some common cases, such as low-risk prostate cancer, the evidence shows that around 25 per cent of cases are overtreated. According to a recent report by the economic consultancy AlphaBeta, eliminating just one area of overtreatment — low-risk cancer patients — could result in an estimated saving of $6 million for insurers through avoided hospital accommodation costs.

Knee arthroscopy procedures are another good example of a high rate of overtreatment, costing the private health system an estimated $105 million each year. Extending private insurance into community-based settings is likely simply to add to these costs.

The funds’ proposal also increases the potential for private patients to be given preferential access to care, which some experts have found already occurs in public hospitals. Primary healthcare is the gateway to the rest of the health system: any inequities at this point in the system are amplified in other sectors, resulting in a less equitable health system overall.

Finally, extending private coverage is also likely to have an inflationary affect, with doctors feeling freer to increase fees knowing that health insurers would have to cover the cost.

Rather than extend private health insurance, we should look at how we can move away from this inefficient and inequitable funding mechanism. More transparent and accountable funding models would better meet Australia’s changing healthcare needs. •

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The latest figures from the Australian Prudential Regulation Authority reveal that 28,000 Australians dropped their hospital insurance in the June quarter, the largest group being twenty- to twenty-four-year-olds. Membership numbers are at their lowest level in fourteen years.

Private health insurance — and particularly the $6 billion rebate and other tax concessions given to policy-holders — has long been criticised by left-leaning commentators for its inefficiency and inequity. But conservative commentators and groups are increasingly adding their voices.

“Neither side of politics in Australia has presented a coherent view of the role of private health insurance,” says Andrew Podger, a former secretary of the health department and the prime minister’s department. “They have left us with a hotchpotch of subsidies and regulations that are confusing, distorting, costly and inequitable.”

Australian Dental Association president Carmelo Bonanno has even advised consumers against taking out private insurance. “While dental rebates represent more than 50 per cent of those paid under General Treatment cover,” he says, “their low levels mean policy-holders would be better off saving their money and paying for dental care only when they need it.”

More colourfully, a former Liberal adviser has admitted that private health insurance is “about as popular as a fart in a lift.”

The problem dates back thirty-five years to when Medicare was introduced without a clear vision of how private insurance would function alongside a universal government-run health insurer. Since then, the private health insurance system has struggled to find a viable role, and has had to be propped up by an increasingly complex (and expensive) system of subsidies and penalties.

None of those measures has succeeded in persuading the majority of Australians that private health insurance is good value. Even in the wealthiest one-fifth of households, only around 80 per cent of households are fund members, despite the fact that in many cases the premiums would cost less than the tax concessions received in return.

Private health insurance is now so complex and confusing that even the health funds themselves have difficulty understanding the details of their products.

Fundamental to this problem is a lack of agreement about the role the private funds should be playing in our health system. Consumers think these insurers are there to protect them from unexpected healthcare costs, and feel let down when they are confronted with high and open-ended expenses.

Doctors (or at least their main representative groups) value private insurance because it funnels people into the private health sector, where earnings are higher than in the public sector. They resist any attempts by the funds to moderate or control gap payments.

Private hospitals want the private health funds to provide a captive market for low-risk, high-volume procedures, such as joint replacements, which provide their highest profits, and then resent the fact that some consumers choose to use their insurance to get access to these services in public hospitals.

Governments see private insurance as a way of extracting more money for healthcare from the community without tax increases, even though the community winds up paying more overall, and even despite evidence that many consumers would prefer private insurance subsidies to be spent on improving public health services.

Private health insurance obviously can’t fill all these roles simultaneously. To earn its place in the Australian health system it has to meet the needs of consumers and the broader community more efficiently and effectively than the alternatives. It shouldn’t be supported because it provides an income stream for providers or props up a system of health financing that no longer serves the interests of the community.

In this light, let’s look at three potential roles for private health insurance and assess their viability.

1. Managing high, unexpected healthcare costs

One potential role for private insurance is to help consumers deal with out-of-pocket healthcare costs, which make up around 17 per cent of Australia’s total health spending, or $29 billion a year. Not all of these costs create problems for consumers, but there is good evidence that difficulties in affording out-of-pocket costs are widespread, and prevent or delay access to essential health services.

Out-of-pocket costs are diverse and can be categorised in many different ways. One way is to categorise them as low-risk, high-cost (such as those associated with major illnesses and injuries); another is to categorise them as high-risk, low-cost (such as those incurred in receiving more predictable and routine healthcare).

From a consumer perspective, those two types are obviously very different. The out-of-pocket costs associated with a low-risk, high-cost event are generally unpredictable and often financially challenging for all but the wealthiest in the community. The highest claim paid by a private fund in 2018 was $531,777, an amount that most Australians would clearly not be able to afford. It isn’t surprising that consumers want to insure against potentially devastating expense.

Judging by complaints to the Commonwealth Ombudsman, this is a key reason why many consumers take out private health insurance. In this sense, it is similar to other forms of household insurance, such as house and car insurance, which share the costs associated with low-risk, potentially catastrophic events among a group of people.

In practice, though, private health insurance doesn’t function like other forms of insurance, which limit consumers’ exposure to high expenses by capping the costs they can incur. In fact, private health insurance generally works in the opposite way, by capping the amount that the health fund pays, leaving consumers exposed to open-ended payments. And the gap payments, exclusions and annual limits included in most private insurance policies can mean that even consumers with the highest level of cover can find themselves facing crippling healthcare expenses with only patchy support from their health fund, particularly for out-of-hospital services.

For private health funds to work as genuine insurers providing cover for high and unexpected healthcare expenses, a cap would be needed on policy-holders’ exposure to open-ended costs. Funds would have to strike fee agreements with medical professionals, something that government can’t mandate. Insurers would also need to cover a greater range of services, and relax current annual limits on claims.

This highlights the problem of designing insurance in isolation from the broader private health sector. If private insurers increased coverage and removed annual limits in the current policy environment premiums would be likely to rise even higher and the downward spiral would continue. Redefining private health insurance, as a genuine insurer of low-risk, high-cost healthcare, can only happen if the government is willing to also tackle the broader policy challenge of out-of-pocket expenses. There’s no easy solution: it will need a comprehensive and multifaceted strategy that goes well beyond the narrow and provider-centric approach taken so far by the government.

2. Managing ongoing, predictable out-of-pocket costs

Private health insurance could support consumers in managing the cost of more frequent and predictable, but lower-cost, forms of healthcare, such as routine dentistry and allied health services like physiotherapy.

For most healthy people, most of the time, these services don’t create overall affordability problems, although some consumers may experience short-term cashflow problems when using them. But for a minority of consumers with very low incomes and/or other unexpected expenses, even these costs can be prohibitive. Research by the Consumers Health Forum of Australia has found that the accumulation of relatively small costs over a long period can be burdensome for some people, especially when added to the other costs associated with illness and injury, such as transport expenses and loss of income.

The Forum’s study is backed up by other research showing that many people delay or don’t use essential healthcare because of cost. The Australian Bureau of Statistics found last year that 13 per cent of people aged fifteen to thirty-four years delayed seeing, or didn’t see, a medical specialist on cost grounds, and 9 per cent of people aged sixty-five years and over didn’t see a dentist when required, for the same reason.

When people delay using essential healthcare, their problems are likely to become more serious, and they can cost the community more over the longer term. Cost barriers are probably one reason why Australia has more than 715,000 potentially preventable hospital admissions every year, according to 2016–17 figures.

Private health insurance does play a role in funding occasional, low-cost healthcare, in particular via extras cover for dental and allied health services. But this isn’t really insurance in the strict sense because it doesn’t cap consumers’ exposure and subsidises services that policy-holders are most likely to use. In practice, extras cover functions more like a prepayment plan for certain forms of healthcare, with the fund collecting regular payments from consumers and in return providing them with a fixed amount towards the cost of an episode of care. And the amounts are usually fairly modest: a typical policy will rebate $28 for a standard physiotherapy consultation, for example.

This may make healthcare costs more predictable, but for consumers wanting to spread their healthcare costs over time, private health insurance is an unnecessarily complicated and cumbersome vehicle. A credit card or another form of payment system, such as Afterpay, would be simpler, cheaper and more user-friendly, and could also be used to cover all forms of healthcare, not just those covered by the private funds.

Private insurance is also unlikely to meet the needs of cash-strapped consumers who struggle to cover even occasional healthcare costs. Even if they can afford the premiums, many consumers report not being able to afford the gap payments that come with using their insurance to access services.

For these reasons it is no surprise that some experts and consumer groups advise against taking out extras cover. The former chief executive of the Private Health Insurance Administration Council, Shaun Gath, once stated that most people would be better off forgoing this form of cover and simply paying for dental, optical and other treatments out of their own pockets. Australia’s leading consumer group, Choice, has also advised consumers to think about dropping their extras cover altogether.

So, given that private health insurance isn’t meeting the needs of those consumers who can’t afford basic healthcare or those who want their healthcare costs to be more predictable and regular, it makes no policy sense for private insurers to continue as funders of low-cost services for people with typical healthcare needs.

A more equitable and efficient use of the public funds currently going into private health insurance would be to help low-income people get access to basic services, and/or to address some of the gaps in the public health system, for example by establishing a universal dental care system.

3. Cross-subsidising healthcare

Over their lifetimes, most people are likely to require significant amounts of healthcare. At any given time, though, the use of healthcare services varies significantly across the population. Older and sicker people generally use much more than those who are younger and healthier. As poor health can reduce earning capacity, people are often least able to pay for health services when they most need them. Spreading the costs of healthcare more evenly across the population, using cross-subsidies from low users to high users, supports equitable access to care and makes sense on both ethical and practical grounds.

Medicare manages cross-subsidisation very efficiently and with a 100 per cent participation rate because it is universal and compulsory. The government-imposed “community rating” requirement — which prohibits private health funds from adjusting premiums according to risk — achieves a degree of cross-subsidy; without it, many people wouldn’t be able to afford private insurance, including those with the highest levels of need.

But community rating also means higher premiums for younger and healthier people than would be the case in a purely risk-rated system. Many low-risk people consequently decide that private insurance doesn’t offer them good value, and so drop their cover. The risk pool of the insured population increases, driving premiums up and causing more low-risk people to drop their cover.

Governments in Australia have tried to counter this effect by subsidising the cost of private health insurance for younger people and penalising the more affluent who don’t have it. The tax rebate to encourage younger and healthier people to take up private insurance currently costs the government around $6 billion, yet young and low-risk consumers are increasingly opting out of the system.

While cross-subsidisation is a valid goal, it is clearly inefficient to pay billions of dollars every year in an attempt to make private health insurance redistributive when Medicare can do that at no additional cost to the community. Governments should focus on achieving cross-subsidisation via Medicare and the tax system rather than relying on the expensive and inefficient mechanism of private insurance.

Private health insurance’s “death spiral” reflects the failure of successive governments to articulate a sustainable role for private funds within the context of Medicare. To resolve this issue, the government needs to decide which (if any) of the possible functions of private health insurance should be preserved and which no longer have a viable role.

We know that many consumers want to be protected against the risk of a catastrophic illness or injury, while others might want help in spreading their healthcare costs more evenly over time, and others need direct support to cover even basic care. We also know that spreading health costs across the population is efficient and equitable.

In its current form, private health insurance doesn’t meet any of those needs well. It is unable to protect consumers from the risk of open-ended expenses; it is an unnecessarily expensive and complex way to help consumers manage their health costs; it doesn’t remove the cost barriers for the most disadvantaged households; and it requires billions of dollars in government subsidies to redistribute costs, which Medicare does automatically.

It is difficult to see how the government can justify an ongoing role for private insurance in its current form, let alone continue to subsidise it to the tune of billions of taxpayer dollars every year. But a narrower role for private health insurance may be welcomed by some consumers who want to protect themselves from high and unexpected healthcare costs. This is a major gap in Australia’s health system and one that has been largely ignored by both sides of politics. Of course, not everyone can afford private health insurance, but the revenue from current rebate subsidies and tax concessions could be used to fund a comprehensive health safety net for all consumers.

If the government is interested in exploring this option it should consider conducting a review of the private health sector, including private health insurance and out-of-pocket costs, along the lines of the review proposed by Labor. This would give Greg Hunt and his colleagues the opportunity to explore alternatives for private health insurance in the context of broader health system reforms and to consult with consumers about their views and preferences. As the debate so far has shown, solutions proposed by those with vested interests are unlikely to reflect consumers’ priorities.

A review would also give the Coalition the opportunity to reassess whether private insurance should be a fundamental part of its political identity. Being wedded to a funding system that has outlived its usefulness is not in the interests of either the current or future Coalition governments. All health funding mechanisms, including private health insurance and Medicare, exist to serve the needs of the Australian community, not vice versa. Abandoning a kneejerk attachment to private insurance could free the Coalition to develop new approaches to health funding that reflect its values while better equipping the health system for future demands. •

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It’s a reminder that the behaviour, trends and policies that constitute my research life are playing out across the developed world in outbreaks of infectious — and preventable — disease. For Will and Sophie, the current measles outbreak in New South Wales feels very close to home, especially since an alert was placed on the bus route through their inner-city suburb. It seems like a very long time until baby Jack can be vaccinated against a disease that hospitalises more than a quarter of the children who catch it, and can be fatal. “It’s crazy that we are having to worry about measles in this day and age,” says Will. “All because some people don’t want to vaccinate their children.”

Will and Sophie don’t face this anxiety alone. Europeans recently learned that the number of measles infections across the continent last year was the highest in a decade, with 82,596 cases reported by the World Health Organization. Seventy-two resulted in death. And that followed a year of bumper coverage, with record rates of take-up for the first and second doses of the vaccine in 2017. Coverage gaps in older populations still enabled the disease to spread.

In the United States, New York City mayor Bill de Blasio declared a public health emergency on 2 April in response to a months-long measles outbreak in ultra-Orthodox Jewish communities in Brooklyn. City officials are resorting to public health measures Americans have rarely seen in living memory. Measles vaccination has been made mandatory in public spaces, and non-compliers risk fines of US$1000, with the threat of compulsory vaccination written into the order. Still, the city stopped short of announcing random checks to confirm children’s vaccination status; instead, officials hope that the declaration itself will encourage people to take the threat of the disease seriously and make use of the highly effective vaccine.

As Will’s comment shows, the popular view is that the problem comes down to ill-informed parents who trust Google over scientific advice. And it’s true that vaccine refusal has played a role in the outbreaks of measles we have seen in recent years in America, Australia and Europe. Unvaccinated individuals have indeed been at the centre of some outbreaks, notably in Disneyland in 2015, when 147 people were infected, most of whom were not vaccinated or whose vaccination histories were unknown.

The internet’s role was even clearer a few years earlier, after an Italian court ruled that a measles, mumps and rubella, or MMR, shot had caused a child’s autism. Italian-language internet searches about the link between MMR and autism — a link consistently refuted by scientific evidence — increased massively. It made little difference that a higher court eventually overturned the decision; MMR coverage rates slumped to 87 per cent in 2015 for one dose in two-year-olds. (While this might seem a high number, 95 per cent coverage is required to protect those who are too young or unable to be vaccinated, or who are immunocompromised.)

But the picture is more complex than that. Globally mobile populations, insufficient booster coverage in adults, and access barriers among disadvantaged groups also contribute to outbreaks. Measles is a heat-seeking missile that finds and infects those without adequate immunity. It doesn’t differentiate between asylum seekers in Europe, Orthodox Jews in Brooklyn, and newborn babies in Sydney. Nor does it care whether somebody is unvaccinated because they can’t get access or because they won’t. But that distinction matters when governments are choosing from a range of potential responses to threats of outbreaks, or trying to maintain high coverage rates. The two groups — the can’ts and the won’ts — couldn’t be more different.

Disadvantaged groups across the developed world are under-vaccinated because government programs aren’t fully reaching them. They include vulnerable communities of refugees and asylum seekers, and low-income families with chaotic lives or other access problems. Adult and young adult populations may also be susceptible for a range of reasons relating to the history of vaccination technology and scheduling in their countries, and may face particular risks when travelling without booster vaccinations to countries where measles is endemic or resurging. They are also at risk when someone else brings measles home.

Free vaccines, available at convenient places and times, with recalls, reminders and follow-ups, can provide these families with protection they are happy to receive. Financial incentives or entry requirements for schools and childcare centres can also motivate families. One thing is clear: health systems must constantly strive to reach individuals whose already complex lives would be significantly worsened by preventable disease.

But what about those families who refuse the vaccines on offer? Are they simply part of a global, Western, high-income phenomenon? Partially. The drivers of vaccine refusal are multidimensional. Some accounts are familiar the world over; others are unique to certain political communities. National characteristics and stories play a role, as do global flows of (mis)information and ideology. International influences intersect with local and national experiences. All inform the vaccine decisions we make, and constrain what governments can do about them.

In high-income areas, one ubiquitous variant of the vaccine refuser is the natural-minded, low-intervention parent. Having pursued a health-oriented pregnancy and a natural birth, and with plans to breastfeed, buy only organic food and resist “junk” culture, some new parents perceive vaccines as unnatural and unnecessary. Social processes may enable such views to dominate particular communities, stymieing vaccine supporters’ confidence to speak up. As vaccine refusal self-perpetuates, the clustering of like-minded families makes their communities more vulnerable to outbreak.

Supporting this trend are celebrities like the Australian chef “Paleo” Pete Evans, who uses his platform as judge of a high-rating TV cooking contest to proselytise against vaccines. Parents’ peers also reinforce the notion that lifestyle vaccine refusers are critical thinkers who like to make up their own minds about what is best for their children’s health. Government responses need to be wary of “cuing” other natural-lifestylers into vaccine rejection by pointing out what “people like them” are doing.

If the natural-minded vaccine refuser is a cross-national variant, local experiences and stories are also grinding away at public confidence, both within specific pockets and nationally. Long before the measles outbreaks in Orthodox Jewish communities in New York, British scholars were examining why Orthodox Jews in London were rejecting vaccines. (The mothers interviewed saw their tight-knit communities as insulated against some diseases and, like other British parents at the time, were influenced by the media to collectively worry about the MMR vaccine.) In France and Italy, controversy over influenza vaccination harmed public confidence. Populations can be unforgiving when it comes to vaccinations, and trust is hard to rebuild.

Governments engaging with vaccine refusal have a number of tools at their disposal, with vaccine mandates the hardest-hitting. The choice will be determined by the epidemiological context, the history and current mix of levers in place, and the political culture of the nation. Beyond funding the high-functioning programs already mentioned, governments should invest heavily in well-researched and targeted communication and social marketing campaigns to normalise vaccination as a health-promoting practice. These can be pitched to subgroups by opinion leaders and peers whom parents trust and identify with, and could involve representing vaccination as part of a natural, healthy and ethical lifestyle.

Language and representation is important. Not all parents who worry about vaccines are “anti-vaxxers,” and public discourse should avoid depicting them as such. Governments need to work hard to reach parents and reassure them that vaccines are safe, effective and necessary. Public commentators would be wise to remember that hectoring worried parents can push them into the arms of the sceptics. In US states such as Michigan and Washington, as well as in Germany, mandatory schemes linking vaccination to access to public institutions or providing financial incentives have also proved relatively uncontroversial when they enable “informed declination” following medical counselling or compulsory education classes. In Australia, they have already been superseded.

Where there is wiggle room for refusers, there will be those who call for tougher measures. Australia, Italy, France and California have all recently tightened the screws, revamping existing vaccination policies to impose consequences on refusing families. Officials report higher coverage as a result, but the fact that these policies are often accompanied by additional investments in vaccine promotion and services means the truth is more complex. Germany and Washington State are talking of similar action, despite only recently revamping their own policies to make opting out of vaccination more difficult.

The consequences that governments impose under such regimes vary vastly, as do the implementation and enforcement. Strict vaccine mandates raise questions about proportionality, effectiveness and moral justification, especially in settings where vaccine refusers are few. Such questions are epidemiological but also political: they prompt consideration of what policymakers actually intend to achieve.

Australians’ widespread, bipartisan support for recent vaccination policy changes indicates comfort with governments telling them what to do. Australians seem to accept the idea that access to public goods might come at the price of limits on their individual freedom. In Italy, by contrast, stricter mandates might have received popular support in opinion polls but voters ultimately ousted the government that brought them in. Many threw their support behind the populist Five Star Movement, which had previously aligned with critics of both vaccines and mandates but is now recognising a public health crisis staring it in the face and dialling up support for vaccination. Globally, political polarisation and populism are drawing in supporters and opponents of both vaccination and mandatory vaccination — which overlap in some political communities more than others. Researchers look with concern to fields like climate change and hope that vaccination does not become similarly embroiled.

Amid this storm, Will and Sophie can take some comfort from the highly effective vaccination programs operating around young Jack. Childhood vaccination coverage rates in Australia have never been higher. But just as the recent measles outbreaks globally have posed threats even in communities with high coverage, their experience in inner Sydney demonstrates that vaccination policies will continue to be political as well as epidemiological. Perceptions that others are placing our loved ones at risk drive policies addressing public concern as much as — or more than — public health findings. •

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