By the beginning of 2024 a record-breaking 21.3 million Americans had signed up for health coverage through Obamacare’s health insurance exchanges — five million more than a record high at the same time last year. Intriguingly, the largest increases have come in Republican-dominated states. In Florida, one in four people under the age of sixty-five are enrolled in an exchange plan; in Georgia, Texas, Utah and South Carolina the figure is more than one in ten.

Much of the recent increase can be attributed to the unwinding of Covid-era rules that made it easier to gain access to Medicaid, the healthcare scheme for people on low incomes. Under Biden, marketplace subsidies for health insurance premiums have been increased and eligibility widened, although this enhanced assistance will expire after 2025 without an extension from Congress. The administration has also boosted publicity about how the insurance exchanges work — publicity substantially reduced under Donald Trump — and removed a glitch that deprived some families of subsidies.

Fourteen years on, the data show that Obamacare is increasingly doing what Obama and the Democrats wanted — not just providing the security of health insurance but also reducing income inequality and racial disparities in healthcare. It has reduced the out-of-pocket costs of preventive healthcare for all Americans and the burden of medical spending on families, particularly those on low and middle incomes. America still doesn’t have the universal coverage standard in other wealthy nations, but some states, including Massachusetts and New York, are getting close.

Trump and Republicans in Congress couldn’t repeal Obamacare in 2017 largely because it had become too popular. It’s even more popular now. Around 60 per cent of Americans support the healthcare law and the figure is even higher for some of Obamacare’s specific provisions, including protections for pre-existing health conditions.

When Trump vowed late last year to “never give up” his call for Obamacare’s repeal — claiming it is “too expensive, and otherwise, not good healthcare” and promising to come up with “a much better, and less expensive, alternative!” — he was offering a campaign gift to Democrats. The promise, which Trump has made frequently since his 2016 campaign without ever detailing a replacement, has contributed significantly to Republican electoral defeats since then. On this issue he has failed to attract a groundswell of support even among Republicans: polling last December by independent healthcare analysts KFF showed that only 32 per cent of self-identified Republican voters considered it very important for candidates to talk about the future of Obamacare, compared with 70 per cent of Democrats.

But that same polling indicates voters are eager to hear the presidential candidates discuss healthcare affordability. Eight in ten voters describe this topic, and the future of Medicare (the federal insurance program for older people) and Medicaid, as “very important.” They regard access to mental healthcare as a healthcare priority too, along with prescription drug costs, gun violence, the opioid crisis, abortion and climate change. (The pandemic barely makes it to the list — only 22 per cent of those surveyed said it was very important.) All these issues and more show up among Biden’s election commitments, whereas Trump’s election statements are vague or absent. (A recent article from KFF Health News outlines what a second Trump presidency could look like for healthcare based on Trump’s previous record.)

Abortion, gun control, immigration, LGBTQ rights and climate change — all issues relating to health — are now seen as “litmus test” issues that drive voting choices. Ironically, though, the most potent policy decisions in these areas in recent years have been made not by elected politicians but by the courts, with the US Supreme Court, now dominated by conservative Trump appointees, as the final arbiter.

This sort of policy rule-making has not always worked well for Trump, Republicans or voters. A classic example is the US Supreme Court decision to overturn Roe v. Wade, the federal guarantee of abortion rights. This ruling delivered Trump and Republicans one of their most significant victories and one of their biggest political vulnerabilities.

Americans’ support for abortion is now at a record high; 69 per cent believe abortion should be legal in the first three months of pregnancy and 61 per cent think that overturning Roe v. Wade was a “bad thing.” Voter anger over abortion restrictions was widely credited with Democrats’ wins in the 2022 midterm elections. This is expected to be the case again in 2024, with abortion on the ballot in many states, even those where abortion rights are legally enshrined.

When asked which party best represents their views on abortion, more people say the Democratic Party (42 per cent) than the Republican Party (26 per cent). Women of reproductive age and young voters see abortion as a factor galvanising them to vote — and American women consistently vote more often than men. Some analysts believe angry Republican women could spell trouble for the party vote in 2024.

Litigation over abortion restrictions and access to reproductive health services is nevertheless proceeding in many Republican-controlled states, and the US Supreme Court is set to rule before November 2024 on two cases involving reproductive rights and healthcare: one on access to mifepristone, the pill used in more than half of US abortions, and another on emergency, life-saving abortions in hospital emergency departments.

Both Trump and his surviving rival in the primaries, Nikki Haley, struggle to articulate a coherent position on abortion that is acceptable to both conservative Republican Party officials and voters. Biden, by contrast, has put reproductive rights squarely in the middle of his re-election campaign. He has committed to enshrining abortion rights in federal law and has issued an executive order aimed at strengthening access to contraception.

The Affordable Care Act and its regulations guarantee coverage of preventive services, including birth control and contraceptive counselling, at no cost for women with health insurance. In 2020 the US Supreme Court upheld a Trump administration regulation that allowed employers with religious or moral objections to limit the birth control cover provided by Obamacare. Last month the Biden administration released proposed rules that would remove the moral exemption but retain the religious exemption, potentially restoring free contraception coverage to 126,000 women.

Abortion and contraception in the United States — a country where maternal and infant mortality rates and healthcare and pharmaceutical costs are shamefully high — are often economic decisions rather than moral or ideological ones. Even in some of the most conservative states with very few abortion services, rates of legal abortions are high. Access to reproductive healthcare services is crucial for many women, regardless of political affiliation, and especially those who are poor. Reproductive health researchers at the Guttmacher Institute say 75 per cent of American women seeking an abortion are either in poverty or just above the poverty line.

It’s worth noting that over the past forty years the sharpest drops in abortion rates have been under Democratic presidents, presumably because of their greater focus on delivering comprehensive healthcare services.

A study released in September 2023 by the Carnegie Endowment for International Peace provides an interesting insight into partisanship more broadly in the United States. Since the Tea Party era there has been almost no policy overlap between the two major parties in Congress (and the situation grows more partisan by the day). Among voters, by contrast, considerable agreement exists even on hot-button issues like abortion and guns.

But voters’ policy views are not strongly held and the American political system doesn’t easily allow them to express their policy preferences. What is strongly held is a sense of identity: what is referred to as emotional or affective polarisation. Voters don’t like people from the other political party — largely based on misbeliefs, misinformation and misperceptions — and will alter their policy preferences to match their partisan identities. In this respect, media like Fox News and Newsmax are seen as having a bigger impact than social media and political campaigns.

The fate of the Affordable Care Act sees two key issues — rising economic pressures and the polarisation of politicians and voters — come together. The act was initially very unpopular because of poor messaging from Democrats and misinformation and disinformation from Republicans and the conservative media. Confusion about a complicated law that took years to come into effect was widespread. And many Americans didn’t realise that the Affordable Care Act (which they liked) was the same as Obamacare (which they despised and/or feared), though those who benefited soon became supporters.

The situation in Florida (an increasingly Republican state) exemplifies the split. Florida has far more people enrolled in Obamacare’s federal health insurance marketplace than any other state. Floridians, bombarded with misinformation from then governor Rick Scott (“everyone now realises that Obamacare was a terrible notion”) and from current governor Ron DeSantis (who wants a healthcare plan that would “supersede” Obamacare), were initially loathe to take up government-subsidised health insurance, deriding it as “socialism.”

But Medicaid has never been expanded in Florida, which ranks among the five most expensive states for healthcare, many local employers don’t offer health insurance, and many retirees are younger than sixty-five and not yet eligible for Medicare. Obamacare offers affordable options for all these groups. Its increasing uptake and popularity has been driven by Republican-leaning Hispanics in the Miami area, where it’s described as “ingrained in the community” and the Obama campaign logo is routinely used to promote insurance.

Despite all this, a November poll showed Florida’s Hispanic voters backing Trump. While only 30 per cent of those surveyed indicated they would “definitely” or “probably” vote for Biden, 36 per cent opted for Trump. Results like these suggest that emotional polarisation will continue to drive voting patterns in November, even if this risks the loss of healthcare insurance and associated benefits.

On the upside, the Affordable Care Act no longer faces quite the same existential threat that once loomed. Despite Trump’s renewed threats, the scheme’s popularity continues to increase and Republican hostility is fading. It has become deeply embedded in the US healthcare system. (It would be no easy task to untangle its provisions from Medicare.) And it will be hard to sell voters a promise to take away the health insurance they know and value — even if there is a replacement, with all its own complicated and time-consuming details. •

The post Obama’a healthcare legacy appeared first on Inside Story.

During those two weeks the Financial Review began a series on “the new middle class.” It opened with a long article analysing survey results that revealed how households on $140,000 a year — a lot of money in those days — didn’t consider themselves particularly well-off. Great, I thought — this’ll make for a solid ten or fifteen minutes. I hurried over to the presenter of the program and showed him the article. “Good God,” he exclaimed after reading the opening paragraphs. “How do people manage on that kind of money?”

Sociologists Marcos González Hernando and Gerry Mitchell open their new book, Uncomfortably Off, with an incident that makes a similar point in a slightly different way. In an episode of the BBC’s Question Time during the 2019 British election campaign, IT consultant Rob Barber accused a Labour MP of lying when he said the party’s plan to lift taxes on high earners would only affect people on the highest incomes. Labour wouldn’t be lifting taxes for the remaining 95 per cent, the MP promised.

“But you are!” Barber replied angrily. “Because I’ve read your policy!” The tax would apply to incomes above £80,000, and that meant he’d be among those who’d pay it. “I’m nowhere near the top 5 per cent, let me tell you. I’m not even in the top 50 per cent.”

Barber was wrong: a salary of £80,000-plus put him comfortably in the top 5 per cent of earners. (At around the same time, an Australian earning $180,000 would have snuck into the same bracket here.) His likely mistake, according to Hernando and Mitchell, was to habitually compare himself with people who earn as much as he does or, more importantly, those who earn much more.

As its title suggests, Uncomfortably Off attempts to explain why people on relatively high incomes don’t feel particularly affluent. (Hernando and Mitchell’s interviewees, all British, were drawn from the top 10 per cent of earners, though not the top 1 per cent.) Partly it’s because, like Barber, they compare themselves with people who earn more than they do. Partly it’s because their spending has increased as their incomes have risen and they have to find the money to cover increases in school fees, rising private healthcare costs and mounting lifestyle expectations.

These pressures contribute to what the authors call a fear of falling — the fear that they or their children will end up further down the income ladder. And those pressures have only worsened in recent years. The Conservative government’s austerity program of 2010–19 encouraged wealthier households to abandon overstretched public schools, healthcare and other publicly provided services, adding to the pressure on household finances, and the growing crisis in British schools, hospitals and community care has only added to the incentive to bail out.

But why would well-heeled earners look up rather than down when they’re assessing their own position? Increasingly segregated schooling and housing, more marriage within rather than between income groups, much less shared experience of healthcare and other social services, a greater focus on paid work and its monetary rewards — these are a large part of the explanation, say Hernando and Mitchell.

“All these tendencies,” they write, “mean that it’s increasingly rare for high earners to get to know people outside their usual interaction with friends, family, work and education, especially when other networks (such as those based on religion or hobbies) either dwindle or move online.” Asked to place themselves in the income hierarchy and feeling under pressure, they compare themselves with the relatively small segment of the population that seems typical to them.

This wouldn’t be quite such a problem if it weren’t for the fact that wealthy people have disproportionate political power. Once they withdraw from the spheres that most people inhabit — government-provided schools, healthcare or childcare, for instance — it’s no longer in their interest for those services to be adequately funded. This sets up a malign cycle: underfunded public services push people who can afford it into the hands of private providers. Their services cost more — often much more — and that puts pressure on their own finances, increasing their resistance to taxes and making them more likely to support government cutbacks.

Some of these trends are hard to reverse. We can’t do much about people marrying within their own milieu, for example. But we can begin the slow process of changing that milieu. The obvious place to start is in the school system, where private schools (generally the preserve of the wealthiest families) are reinforcing social segregation to an alarming degree.

Hernando and Mitchell conclude that cracks are opening up in the fearful barriers wealthy Britons have erected against an increasingly underresourced public sphere. “This book’s aim is to invite the top 10 per cent to consider a future in which, for the price of giving up the barriers through which they seek to distinguish themselves from the rest” — a price that would include higher taxes — “they could become less anxious, more secure and less isolated.”

Can Australia learn from Britain’s uncomfortable wealthy? While 7 per cent of British children are educated in private schools, the Australian figure is 35 per cent. Add in selective government schools, particularly in New South Wales, and our school system rates among the most segregated in the Western world. But the groundswell of support for the Gonski report (before it was fatally compromised by federal and state governments of both varieties) shows the soil is fertile. •

Uncomfortably Off: Why the Top 10% of Earners Should Care about Inequality
By Marcos González Hernando and Gerry Mitchell | Policy Press | £19.99 | 256 pages

The post Fear of falling appeared first on Inside Story.

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.

It’s almost a decade since I wrote those words in the Medical Journal of Australia — and yet, despite a succession of papers, reports and policy proposals, surprisingly little progress has been made. The consequences, and the dollar costs, of poor oral and dental health, often preventable, continue to drag on the community.

It’s well recognised that dental decay and tooth loss can cause pain, problems eating and speaking, and loss of self-esteem. But poor oral health is also linked to heart disease, diabetes, stroke, pneumonia, autoimmune diseases like rheumatoid arthritis, chronic kidney disease, dementia, low-birthweight babies and more. In older people it is associated with a greater risk of all-cause mortality.

Apart from poor dental hygiene, oral ill-health can be brought on by certain medical conditions and treatments, including diabetes, HIV/AIDS, osteoporosis, lupus, Sjögren’s syndrome (dry mouth), chemotherapy and radiotherapy, and a range of medications.

Dentists play a key role in screening for oral cancers. While these cancers are more common in older smokers, recent research shows an increase in diagnoses among young Australians without identifiable risk factors. In particular, the number of women under forty-five diagnosed with tongue cancer is rising significantly faster than for women over forty-five and men.

For those reasons alone, better integration of dental and medical care should be a priority. Many patients with coexisting medical and dental issues require multidisciplinary care plans involving doctors and dentists. Collaboration of this kind improves the quality of care and its results, including patients’ quality of life.

Given the costs (to both the healthcare system and patients) and the consequences of a failure to better integrate dental and medical care, increased access to affordable dental services should be a particular priority. This need could and should be considered separately from the provision of universal dental care: it goes beyond the preventive and early-intervention measures that ensure a healthy smile to the health of the body as a whole.

The current system’s failures are especially pronounced for two categories of patients: those with congenital heart disease, or CHD, and those with cancer, especially cancers of the head and neck. Patients with CHD and gum disease are particularly at risk. The bacteria that cause gum disease can cross into the blood stream, enter the heart chamber and directly infect the valves. These patients need special care for even the simplest dental procedures, and additional screening and safeguards before any surgery.

A German study published in 2022 found that children and teenagers with CHD were significantly more likely to experience dental decay and inadequate dental hygiene. This may be because their regular hospitalisation is interfering with normal dental check-ups, a deficiency exacerbated by a shortage of experienced paediatric dentists.

There’s no reason to believe the situation is any different in Australia. While national data are lacking, the paediatric dental team at Westmead Children’s Hospital found that about 27 per cent of children with CHD had a history of dental infections. The cost of extractions (the majority of services) and restorations under anaesthesia for these children is substantial: the mean number of days in hospital was 1.43 and the mean cost was  $4395 per child treated. The paper makes the point that clear referral pathways to dental care are a key need for children with CHD.

Richard Widmer, the leader of the team, told me that he and his colleagues often spend many hours and thousands of dollars on dental care before Westmead’s patients, often from regional and rural New South Wales, can get the operations they need. This is a potentially avoidable burden on the public health system and obviously distressing for the children.

A witness at the current parliamentary inquiry into dental services described how a patient at St Vincent’s Hospital in Sydney had a left-ventricular assist device implanted at a cost of more than $150,000. This life-saving work was almost undone because his poor oral health, which was not assessed before the operation, caused a life-threatening infection. The patient needed costly intensive care and further surgery.

Cancer patients — especially patients with head and neck cancers — also need special attention. They often have poor dentition to start with, have faced surgery, chemotherapy and radiation therapy, and must then manage chronic dental problems that frequently worsen over time.

Nectarios Andrews, a dentist who works with multidisciplinary head and neck teams at several Sydney hospitals, describes the people he works with as the “most vulnerable of patients” who have “already battled a cancer diagnosis [and] are too often doomed to a life of devastating dental pathology with crippling functional and emotional outcomes.”

New technologies and techniques are delivering remarkable results for these patients. Jonathan Clark’s team at Chris O’Brien Lifehouse in Sydney has a dedicated craniomaxillofacial reconstruction program that combines advanced reconstructive surgical techniques (using dental prosthetics produced by 3D printers) with virtual surgical planning (where the surgery is digitally simulated to increase the accuracy of reconstructive surgery). Evidence suggests these procedures deliver clinical benefits and increased rates of dental rehabilitation, leading to improvements in key health-related quality-of-life outcomes, including speech, aesthetics, swallowing and eating.

Too often, though, the amazing multidisciplinary treatment and care delivered to these patients in (mostly public) hospitals can’t be completed because specialised dental services are lacking. Hospital-based dental services are only available for low-income healthcare card holders and most patients with head and neck cancers can’t afford private dental care that can cost as much as $100,000 beyond what is covered by health insurance. Some patients have very complex requirements for which general dentists are neither trained nor equipped.

As impressive and affordable as the work is at Chris O’Brien Lifehouse, only one-in-ten patients are dentally rehabilitated following oral cancer surgery. New public and private funding options are needed to improve patients’ access to these services. As it currently stands, many patients come through extensive surgery and treatment for oral cancers only to face poor quality of life because they can’t get access to dental prostheses and ongoing dental care.

Better links between oncology, hospital-based dental services and private dentistry are also needed. Dental information is shared in some but not all cases to assist dentists looking after these patients in the community, but dental records are excluded from My Health Record. This information is crucial: cancer patients who have had, for example, extensive radiation to their jaw are at risk of poor healing after dental extractions.

Australia’s National Oral Health Plan 2015–2024 identifies four priority population groups with relatively poor oral health and inadequate access to care. These include people with additional and/or specialised healthcare needs, a category that covers most of the patients described above.

The parliamentary committee’s interim report makes mention of the need for greater coordination between medical and dental services. It quotes one witness stating that “preventing (oral) infection is a medically necessary service and therefore essential health care” (emphasis in the report).

Peter Foltyn, a consultant dentist at Sydney’s St Vincent’s Hospital, is quoted as recommending that any oral and dental health services needed before medical treatment should urgently be integrated into the Medicare Benefits Schedule, or MBS, and that medical undergraduate training should include education on the important relationship of oral health to systemic health.

If they meet certain requirements, dentists already have access to a number of MBS items. These include items for multidisciplinary case conferencing and the preparation of treatment plans for cancer patients; consultations (including telehealth) for oral and maxillofacial patients; and assistance at operations. But no analysis of the use of these items is publicly available, and they apply only to services delivered either in the community or to private patients.

Even if new Medicare items and increased funding for public services were provided tomorrow, little will change for patients unless and until medical and dental cultures change and professional siloes are broken down. This has been done successfully in other medical settings — mostly in multidisciplinary cancer teams — but this kind of integration needs to be universal.

The key barrier is medicine’s and dentistry’s distinct education systems, clinical networks, records, and funding and insurance arrangements. Necessary changes would include interdisciplinary education, shared training, and a recognition that dental services are an integral part of primary care and essential for the treatment of some medical conditions.

An article published  several years ago in the Australian Journal of General Practice did an excellent job of exploring the history of the medicine–dentistry divide and the challenges it creates, and suggested how these might be tackled. Its authors made a strong case that education is the place to start.

A 2018 study of the hours dedicated to oral health education in medical schools in Australia highlighted that imperative. It showed that Australian medical school graduates have little if any foundational knowledge of oral health, including dental caries, oral cancer, dental emergencies, and the relationship between diabetes and periodontal disease. Only a few hours in multi-year programs were dedicated to teaching these topics, and no medical school reported hands-on training in an oral health setting.

We can hope that things have changed since that study was published, but only an optimist would believe that the shift has been sufficient to overcome the current siloes.

It’s time for the federal government to make the system changes and introduce the financial incentives across both the public and private sectors that will push medicine and dentistry into a partnership to improve health and health outcomes for all Australians, starting with those most affected by poor dental and oral health. •

The post The dental divide appeared first on Inside Story.

Recent censuses have documented a quite extraordinary growth in the Indigenous population, largely in southeastern Australia, driven by growing self-identification and rising numbers of mixed Indigenous and non-Indigenous relationships. As a result, the national profile of the Indigenous population is changing, accompanied by even greater levels of income inequality. Very high levels of income inequality exist within the Indigenous community, levels that are greater than those that exist within the non-Indigenous community.

Alongside these shifts has been a growth in the diversity of political perspectives among leading Indigenous figures. The contrasting views of Indigenous No campaigners Jacinta Nampijinpa Price and Nyunggai Warren Mundine, on the one hand, and Lidia Thorpe and author/lawyer Michael Mansell, on the other, are just one example.

The geographical, social and linguistic heterogeneity of Indigenous Australians has long been recognised by policymakers yet only sometimes taken account of. The regionally organised Aboriginal and Torres Strait Islander Commission (1990–2005) was a rare example of a positive recognition of heterogeneity; in other cases — tighter conditions on social security in remote Australia, for instance — the recognition has come with a punitive veneer.

This diversity has increasingly been overlaid (though not replaced) by a pan-Indigenous focus on identity and identity politics that has begun to permeate the national imagination. The emphasis on a single identity — rather than on layered identities, as Noel Pearson advocates — has created a unity with its own fragility.

These strands have created social, economic and political complexities that undercut the possibility of building an enduring consensus among First Nations on virtually any issue. If substantial Indigenous consensus on policy aspirations is just as elusive as it is among the non-Indigenous population, then all-encompassing Indigenous representation is inherently elusive, particularly nationally.

The referendum result alone won’t drive this complexity; it has been emerging for at least two decades. But the vote will inevitably be perceived as a political and societal inflection point. The notion that governments should seek to discern an overarching and representative Indigenous perspective is likely to give way increasingly to multiple Indigenous interest groups, themselves engaged in the cut and thrust of interest-group politics both within the Indigenous domain and between the Indigenous domain and the wider political domain.

Virtually all recent public commentary has been on the politics of the Voice: the campaign, the tactics of the Yes and No camps, the effectiveness of the most prominent advocates, the implications for social cohesion and reconciliation, and the implications for Australia’s international reputation. The shape of the post-referendum policy framework has received almost no attention. Yet it will determine the opportunities available to First Nations citizens and inevitably shape the nation’s future in ways that are difficult to predict but nevertheless consequential and far-reaching.

In a hyper-rational world, the obvious response to the referendum loss would be to press ahead with legislation to create a Voice. After all, if it is important enough to be constitutionally entrenched, why wouldn’t the government seek to establish it legislatively?

We don’t live in an entirely rational world. Prime minister Anthony Albanese explicitly ruled out a legislated Voice before the vote, primarily on the basis that the process of legislating a Voice would become hyper-politicised. Opponents would argue that the referendum result made crystal clear that Australians don’t want a Voice, thus depriving any such proposal of an electoral mandate. Its design would become deeply contentious both in wider political circles and among Indigenous interests. Without constitutional enshrinement, a legislated Voice’s views and policy perspectives would arguably carry less weight and be more susceptible to being ignored by governments.

One alternative path would be to create an appointed Voice, though the prime minister appears to have implicitly ruled this out too. Governments often appoint specialist groups to provide advice; in fact, the previous government appointed a prime minister’s Indigenous Advisory Council in September 2013 with Warren Mundine as its first chair. It was silently abandoned in 2019 when its advice on how best to progress the Uluru Statement and the proposed Voice became politically inconvenient.

Since then, reflecting the triumph of political considerations over rationality, the Coalition government (and now Labor) operated without a formal Indigenous advisory mechanism while simultaneously funding elaborate bureaucratic and legal processes to design and implement a proposed Voice.

The government’s most likely move will be to embrace the role of the Coalition of Peaks, the alliance of eighty-plus Indigenous peak bodies that emerged in early 2019 from discussions between representatives of fourteen Aboriginal community-controlled organisations and prime minister Scott Morrison. Those discussions ultimately led to the National Agreement on Closing the Gap. According to its latest annual report, the Coalition of Peaks directly and indirectly represents more than 800 organisations and at least 550,000 Indigenous people across numerous sectors.

Announcing a greater reliance on the Coalition of Peaks — or, more probably, gradually lifting engagement — has several political advantages. The coalition encompasses a wide swathe of Indigenous policy, it was established and funded by a Coalition government, and it is capably led by its convenor, the experienced former bureaucrat Pat Turner. Perhaps even more importantly, building on the coalition requires no legislation and can accurately be characterised as a continuation of the status quo.

If it pursues this option, Labor will presumably take the opportunity to signal its increased commitment by allocating new Indigenous funding in the coming 2024 budget. One obvious spending opportunity championed by Turner and the Coalition of Peaks is housing, a policy domain with implications for health, education, criminal justice and domestic violence. As the government develops its new National Housing and Homelessness Plan, which will encompass new intergovernmental funding arrangements, it could earmark increased funding to Indigenous communities.

The Coalition of Peaks is, of course, quite different from the proposed Voice. Unlike previous Indigenous representative bodies, it seeks to represent the interests of “community-controlled” organisations rather than the entire Indigenous constituency. Its members cover a broad range of Indigenous interests, but obvious gaps include the educational and economic development sectors. Implicit in any greater engagement would be a shift to engaging with coalition’s constituent peak bodies.

At the core of the Coalition of Peaks is NACCHO, the National Aboriginal Community Controlled Health Organisation, which represents 145 Aboriginal community-controlled health organisations across the country employing around 6000 staff. NACCHO’s members service more than 550 primary care sites delivering more than 3.1 million episodes of care to more than 400,000 people.

Apart from their sheer breadth of activity, NACCHO members have the advantage of receiving mainstream healthcare funding for their services, thus ensuring a substantial level of political independence. That advantage does not extend to most of the Coalition of Peaks’s other members, which rely to a greater or lesser extent on discretionary government funding. So too does the Coalition of Peaks’s policy secretariat, creating a major risk to its continued independence.

As a member of the council overseeing the National Agreement on Closing the Gap, the Coalition of Peaks has guaranteed cabinet-level access to every jurisdiction in the Australian federation. This is unprecedented in modern Australian history, though the reality is that it is outnumbered and outgunned by the sheer institutional heft of the states and the federal government, and particularly by the size and intellectual capital of their bureaucracies.

Of course, governments will continue to engage with Indigenous interest groups outside the Coalition of Peaks, and will draw on specialist advisory bodies where necessary, as already occurs in the mainstream policy domain. When both Indigenous and non-Indigenous interests are involved, governments will continue to appoint Indigenous members to relevant advisory committees.

The advantages of using the Coalition of Peaks to underpin the future framework of Indigenous policy are significant, but there are also significant challenges.

Foremost is the fact that the extraordinarily complex policy architecture of Closing the Gap is unfit for purpose and requires serious attention. Its bureaucratic complexity ties the Coalition of Peaks down in never-ending process, across eight jurisdictions, virtually guaranteeing it cannot focus consistently on strategic policy opportunities. Complicating its work is the fact that the Coalition government shifted political responsibility for most targets to the states and territories and stepped back from any overt leadership role, a move not reversed so far by Labor.

These problems should have been tackled head-on in the Productivity Commission’s recent draft report on the National Agreement on Closing the Gap. Although the report is critical of progress, its strategically underwhelming analysis is a lost opportunity to take stock and shift course to ensure governments take their commitments seriously. The machinery of Closing the Gap will not collapse in the short term, but neither will it survive into the medium term without focused attention.

Governments are inherently conflicted on this issue: reform of the policy architecture and a stronger Coalition of Peaks will inevitably make life harder for them. Visionary political leadership within government, always in scarce supply, will be required to crack this nut.

A second implication of the referendum defeat is that governments and First Nations will be forced to reconsider the preparedness of the Australian electorate (and the nation’s underlying political settlement) to accept treaties as a mechanism for advancing Indigenous aspirations. While many First Nations leaders and their supporters will intensify their calls for treaties, the risk of devoting decades of work to inchoate policy reforms, and the challenges of agreement-making with reluctant governments could fracture Indigenous views on the benefits of such a strategy. Pragmatic leaders could well see better and more immediate uses for scarce advocacy resources.

It is also worth mentioning that while a successful referendum would have paved the way for a vote on an Australian republic, the defeat is likely to dampen enthusiasm in the current decade. Perhaps paradoxically, it may also increase the likelihood of an Indigenous person being appointed as Australia’s head of state in the interim.

Progress on Indigenous constitutional recognition, meanwhile, appears more remote than ever. Short-sighted self-interest has triumphed over visionary reform. The 1967 referendum gave the Commonwealth an implicit mandate to lead on Indigenous policy, one it has progressively walked away from over the past decade. The Indigenous leadership, encouraged by progressive Liberals, decided to shift away from the recommendations of the 2012 report of the expert panel on constitutional recognition and replace it with the Voice proposal, a move that now seems a well-intentioned error of judgement.

Led by Pat Dodson and Mark Leibler, the expert panel recommended the repeal of section 51(xxvi) of the Constitution, which allows the federal government to enact adverse and discriminatory laws based on race, and called for a new provision prohibiting racial discrimination.

The nation’s Indigenous policy framework over the coming decades will inevitably focus on particular Indigenous interests rather than a notional general interest, tempered by more of the same: more rhetoric over substance, more evasion of responsibility, more blame shifting, less transparency and ministerial accountability, and continued policymaking aimed merely at giving the appearance of action.

If they are to force their way into the dominant bloc of interests that controls Australia’s institutions, Indigenous interests will need to look beyond governments for support and as the sole locus of political action. To be effective, they must build alliances, institutionalise the independence of their advocacy capabilities, and create their own policy institutions. They will need to span their diverse aspirations, and build and sustain the intellectual capital necessary to achieve inclusionary policy reforms in the face of opposition from mainstream interests concerned to protect the status quo. Inevitably, this will be a multigenerational struggle. •

The post Indigenous policy’s inflection point 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

The post Treat the patient, not the x-ray appeared first on Inside Story.

In government just a year later and in power for almost a decade, the Coalition made frequent promises to lift the uptake of private health insurance even as doubts intensified about its value and cost. Along the way, private hospitals labelled private insurance as the health system’s “weakest link” and the private health funds themselves worried about an exodus of customers.

With analysts increasingly predicting a health insurance industry “death spiral,” the Morrison government made moves over several years to — as officials described it — “improve the value proposition of private health insurance for all Australians.” In reality, that was code for the government’s efforts to rescue the funds from what industry insiders have called “the jaws of death.” (Together these concerns raise the question, to which we’ll return, of whether the funds have any useful role to play.)

The changes enacted by the Coalition were mostly ineffective. Efforts to make health insurance policies easier to understand were undermined by industry lobbying, leaving the system as confusing as it ever was. Discounts for younger members appear not to have lifted the participation rate for hospital cover.

A deal to keep premiums lower was undermined by the failure to achieve savings on the prostheses list, a government-maintained register of medical devices for which insurers are required to pay a benefit. A costs-finder website designed to reveal out-of-pocket costs for specialist medical services has done nothing to increase the affordability and uptake of private insurance.

Through those years the means-tested rebate remained untouched. Never a government to take on difficult issues, the Coalition was confronted with the reality that meaningful options were risky, controversial or both.

Labor’s current consultations on private health insurance had their genesis in Coalition health minister Greg Hunt’s review of the sector, which he launched in July 2019. “I’ve already been meeting with private hospitals, insurers and medical leaders on the next stage in terms of private health insurance reforms,” he said at the time. A few months later he reported that he was working on ways to enable health funds to cover hospital-in-the-home and specialist treatment delivered outside hospitals at a lower cost, starting with mental health and orthopaedics.

This work appears to have stalled. The 2020–21 budget papers announced that the Morrison government would begin consulting the private funds about expanding community-based mental health and rehabilitative care in October 2020, with the changes to take effect on 1 April the following year. I can find no evidence that progress was made towards this goal.

The following year’s budget papers proposed a review of the Medicare levy surcharge (a penalty payable by higher earners who don’t have hospital health cover) and the private health insurance rebate (the means-tested government subsidy to help offset the cost of private insurance). They said that the prostheses list needed modernising and its administration improved, and foreshadowed scrutiny of private hospital default benefit arrangements (the benefits insurers pay to private hospitals if they have no standing financial agreement).

The need for reform has only intensified since Labor took office. Housing and cost-of-living pressures mean that many people, especially if they’re young, can’t afford an expensive discretionary purchase like private insurance. Out-of-pocket costs for private healthcare services continue to rise. The ageing of private fund members is threatening the funds’ sustainability. The cost to government of the private insurance rebate is expected to be around $28 billion over the four years from 2021–22.

But private insurance reform is not a topic health minister Mark Butler is talking about, at least in public. In his media releases and statements this year I can find only one passing reference to the government’s reform program: a mention of reducing private health prostheses prices and enhancing the Medical Costs Finder. The work on major reforms appears to be happening under the radar.

Given the impact any changes could have on all Australians, it’s surprising the health minister isn’t keeping the public informed. We can be sure the other stakeholders — the health insurance industry, the private hospitals and the doctors’ groups — are being kept in the loop.

Labor’s work draws on commitments made by the Coalition in recent years, and reports commissioned by its last health minister, Greg Hunt. But tracking the efforts of both governments is hindered by a lack of transparency and a dearth of publicly accessible documents. Complicating the task is the fact that many of the proposals currently up for analysis and discussion are highly technical, demanding expertise in insurance, taxation and risk management that most health policy experts — let alone the general public — lack.

An online search for official information on private insurance reform reveals a single page on the health department’s website — and despite being dated July 2023 it is clearly a relic of the Morrison era. An invitation to find out more about the reforms it mentions takes the visitor to a budget 2021–2022 fact sheet.

The government’s consultation hub is more forthcoming. It includes a report from consultancy firm EY on hospital default benefits and reports from Finity Consulting on lifetime health cover (May 2022), risk equalisation (September 2022) and a mix of other insurance issues (2023).

This is where the story gets complicated. The latest Finity report recommends retaining the Medicare levy surcharge, the insurance rebate and lifetime health cover (no surprises there), and offers options for optimising both the surcharge and the rebate by targeting incentives more effectively. It offers no options for reforming lifetime cover, with the implication that this is inextricably linked to changes in the surcharge and the rebate.

In its earlier lifetime cover report, Finity found evidence that the penalties for delaying the purchase of private insurance, or for purchasing it only when it was felt to be needed, were having a weaker effect and/or becoming less relevant for younger Australians faced with financial constraints.

A single-page departmental consultation paper requests feedback on these studies’ recommendations and how they might be implemented. It also seeks views on a number of policy and regulatory issues not canvassed in the consultants’ reports and wants to hear back about “the readiness of participants in the private health sector to work constructively together to the benefit of policyholders and the performance of Australia’s private healthcare system, and whole of sector mechanisms that can facilitate this outcome.”

The consultation period was open from 6 June to 15 August. The consultation paper had mysteriously disappeared from the consultation hub when I looked for it on 20 August but was reposted after my email enquiry. No submissions have yet been posted on the website. While we can assume that Private Healthcare Australia (the industry’s peak representative body), the Australian Private Hospitals Association, medical organisations and, it’s to be hoped, consumer and patient groups are keenly interested in the outcomes, to date only the Australian Medical Association and the Australian Private Hospitals Association have made their submissions public.

A separate consultation process on EY’s recommended changes to hospital default benefits arrangements took place in August–September 2022, but despite the release of a consultation strategy the recommendations appear to have gone no further. Without changes to the current default policy, patients using smaller hospitals and hospitals in under-serviced areas will be increasingly out-of-pocket, or those hospitals will receive increasingly inadequate compensation.

Thankfully, a paper by several academics who worked with Finity Consulting helps navigate through this welter of studies. According to its authors, the studies have produced three key findings: that financial incentives for consumers to purchase private health insurance are effective overall but inefficient in achieving their desired objectives, including reducing pressure on public spending; that options for reforming those incentives have been designed only as short-term solutions; and that price changes have little effect on insurance uptake.

Reduced to these three key points, the consultants’ work can justly be regarded as unnecessary. A succession of recent analyses and reports from universities and elsewhere have shown how incentives to take out private insurance do and don’t work and what might be done to improve its value for those who purchase it.

A 2021 paper from ANU’s Tax and Transfer Policy Institute looked at the effectiveness of various sticks and carrots used to encourage private insurance, in particular the changes made by the Gillard government in 2012. It found that the Medicare levy surcharge had a greater bearing than the premium rebate on decisions to purchase insurance.

Research by economists Yuting Zhang and Nathan Kettlewell, on the other hand, showed that increasing the levy surcharge wouldn’t meaningfully increase take-up of private insurance because higher-income people who aren’t already buying insurance appear to be highly resistant to financial incentives and disincentives.

A four-step plan to fix the private health insurance system released by the Grattan Institute called for restraints on price-gouging specialists, measures to stop insurers increasing premiums if they can’t demonstrate value for money, and market competition to control the costs of prostheses.

Amid these reports, what messages have the insurers and providers of private healthcare been pushing in their communications with government, the media and the public?

Private Healthcare Australia, the funds’ lobby group, is strongly focused on two issues: restoring the full private insurance rebate — removing the means test, in other words — and cutting back the costs of medical devices, which are much more expensive in private hospitals than in public hospitals. It recently called for a review of the Morrison government’s prostheses changes, which it described as an “inflationary medical device deal.” Tackling both these issues, says the group, will lower premium costs and increase the uptake of private insurance. (Mark Butler announced a series of changes to the prostheses list in January 2023, but they won’t be fully implemented until July next year.)

The Australian Private Hospitals Association argues that the appeal of private insurance will decline if private hospitals aren’t viable. It accuses the funds of profit-taking at the expense of the long-term viability of private hospitals. The association objects in particular to the default funding arrangements for the treatment of private patients in public hospitals.

The Australian Medical Association deserves some credit for recognising the impact of high-priced health insurance premiums on patients. Its submission to the consultation pushes reforms the AMA first put forward in 2020, including the creation of a Private Health System Authority charged with protecting patients, instilling confidence in this highly complex system and driving reform. The AMA has also called for the private health sector to adopt (and fund) more innovative and efficient models of care, including home- and community-based care.

The loud voices of these well-resourced organisations are not easily ignored by governments. The needs, concerns and growing dissatisfaction of the general public, meanwhile, aren’t readily marshalled, presented and heard. While the biggest concern in the community is that insurance should deliver value for money and be accessible when needed, the evidence shows that many Australians value public hospitals more, especially in a crisis. One in four patients who hold private insurance choose to use public hospitals.

What’s glaringly absent from the current consultations are several basic questions that deserve to be taken seriously. Chief among these is whether the government should withdraw its financial support for private insurance altogether and invest the billions of dollars it would save in Medicare and public hospitals (or cut out the funds and directly support private healthcare).

Which of course raises the question of whether private insurance actually does reduce the burden on public hospitals — a belief challenged by recent research from the Melbourne Institute (summarised in the Conversation) that found it doesn’t make much difference to hospital admissions and waiting-list times.

In debating the public–private divide, it’s important to separate the delivery of private healthcare from private insurers, which are simply financial intermediaries — and surprisingly small ones at that. Australia’s total health budget in 2020–21 was $220.9 billion, of which governments contributed $156 billion, individuals $33.2 billion and private insurance $18 billion. Moreover, to quote insurance industry expert Ian McAuley, there isn’t any aspect of private insurance that isn’t done more efficiently and more equitably by Medicare.

The debate on these issues has always been hindered by the fact that Medicare was introduced without planning for how two health insurance systems, Medicare and private insurance, would coexist. Now might be the time to face the problem squarely.

I have yet to see any response from health stakeholders to the government’s plea for signs of a willingness to cooperate constructively for the benefit of health consumers — but that is surely what is needed if the necessary reforms are to be made. A new openness with the public about the existing consultations would be a good place for both the health minister and his department to start. •

The post The weakest link appeared first on Inside Story.

I have been thinking (and writing) about the prospect of emerging pandemics for most of my professional life. I started my career as an infectious diseases physician in the 1980s just as HIV was emerging and have seen Lyme disease, hepatitis C, SARS, MERS, H5N1, Ebola, Nipah, hantavirus, bat lyssavirus and monkeypox (to name a few) appear and recede. I thought the next pandemic would be a bird influenza that had been “humanised,” but wiser observers saw the risk of a coronavirus with the right genetic profile.

Although border closures formed part of existing control plans, I didn’t believe that any liberal democracy would close itself off from the world, and the state border closures in my own country were unthinkable — until they happened. I did expect mass gatherings to be cancelled but never imagined entire populations confined to their homes.

Yet just three and a half years after its sudden appearance, I skim academic articles about the virus and altogether avoid general media coverage. This may be an adaptive response to trauma, and a sign that we trust that the technocracy and polity have learned enough to mitigate the effects of the next inevitable event. Or is it something else?

In his new book Foreign Bodies, historian Simon Schama shows how eighteenth- and nineteenth-century authorities, scientists and societies dealt with large-scale outbreaks of smallpox, cholera and plague. Each case shows the “immemorial conflict between ‘is’ and ‘ought,’” Schama writes,

between short-term power plays and long-term security… between the cult of individualism and the urgencies of common interest… between native instinct and hard-earned knowledge. If it is a happy answer you want to the question as to which will prevail, it is probably best not to ask an historian.

Foreign Bodies opens, appropriately in this age of wilful intellectual amnesia, with the French philosopher Voltaire, who nearly died of smallpox in 1723. Because it is the only infectious disease that has been eradicated from the planet, we have no contemporary experience of the terror it inflicted on local populations when it appeared. But smallpox not only killed a significant proportion of any group of people it infected but usually left survivors scarred and disfigured.

Voltaire was contemptuous of how doctors treated the disease in France. In his Letters Concerning the English Nation (1733) he cites the use of inoculation in Britain as an example of that country’s modernity. What he may not have known is that inoculation had only recently, and indeed reluctantly, been introduced from the East.

Smallpox inoculation was very different from the vaccination that came later. It involved pricking smallpox pustules on an infected individual and transferring the extracted fluid into a healthy subject — usually by making a number of superficial pricks of the skin with the contaminated needle. The vast majority of inoculated subjects suffered only a mild to moderate attack of smallpox, although occasionally they died. We still don’t know why inoculation produced a less severe disease than “naturally” acquired infection.

Britain’s adoption of inoculation, patchy and fragile as it was, was driven by an unlikely eighteenth-century influencer. Before she returned from Constantinople to England in 1718, Lady Mary Wortley Montagu, wife of the English ambassador to an Ottoman sultan, had access to a female world closed to her husband. She had been struck by the absence of smallpox scarring in the women she met socially and observed in harems.

Montagu — who had herself been disfigured by an attack of smallpox — learned that the disease’s effects were minimised by the local practice of inoculation. She brought this knowledge back to London and convinced an English surgeon to inoculate her son. The practice was slow to catch on, but Montagu’s political connections meant that Caroline, Princess of Wales, became aware of her advocacy and had her two daughters inoculated. Even Catherine the Great eventually followed suit.

At this distance, the medical profession’s resistance to inoculation isn’t surprising, but it is ironic, considering that medics at the time lacked effective treatments for almost any disease. When the English profession did adopt inoculation, doctors couldn’t help but combine it with mercury, antimony and other useless (and even dangerous) but popular medications. Lady Mary despaired of this meddling, wishing that the protocol would stick to that of the East.

Schama touches on the trope of wise folk remedies versus mainstream medicine in recounting Lady Mary’s story, but he is always aware of the risk of lionising success after the event. Effective treatments have a survival advantage, dangerous ones disappear — eventually.

On balance, inoculation was a useful and relatively safe procedure. But it was supplanted when Edward Jenner introduced vaccination in 1796. Others had already observed that milkmaids, who rarely contracted smallpox, had almost always been infected with a trivial infection known as cowpox (or vaccinia in Latin). Jenner was not the first to infect patients with cowpox to prevent smallpox, but he formalised the procedure and promoted its widespread use.

In this case, the close relation of the viruses that caused cowpox and smallpox provided a serendipitous protective cross-immunity. But nature doesn’t provide many similar serendipities. It would be ninety years before Louis Pasteur developed the next human vaccine, in his case against rabies. Although viruses had still not been identified as a cause of disease, he “passaged” the infectious material through generations of rabbits, eventually producing an attenuated or “live” vaccine designed to provoke a protective immune response without causing the disease itself.

The first acknowledged recipient of Pasteur’s vaccine was a nine-year-old boy, Joseph Meister, who had recently been bitten by a rabid dog. As Schama points out, the usual triumphalist history of the discovery is complicated somewhat when we learn that two subjects had received the vaccine prior to Meister, and one of them had died.

Three exciting decades of microbiological discovery followed Robert Koch’s identification of the anthrax bacillus in 1876. The bacterial causes of many of the important epidemic infectious diseases — plague, tuberculosis, cholera and salmonella, to name a few — were elucidated in short order. Because it isn’t easy to prove that a germ actually causes a disease, Koch postulated the criteria that needed to be met.

It is here, in the context of a persisting uncertainty about the true cause of epidemics, that Schama introduces the unlikely character of Adrien Proust, the father of Marcel. Proust the elder, a public health physician in late-nineteenth-century France, advocated an international body to coordinate responses to epidemics and promote the very new science of vaccination. Representing France at a conference on cholera in Constantinople, Proust had heard the Ottoman Sultan Abdulaziz discussing the health risks for home countries of those returning from the Haj — a topic that remains germane today.

Cholera epidemics were widespread in Europe at the time, and international politics and professional differences were hampering control. Schama argues that while the British were motivated partly by mercantile interests anxious to keep ports open, a medico-philosophical argument was also in play.

The latter reflected one of the key moments in the history of infectious diseases: London-based physician John Snow’s discovery in 1854 that contaminated drinking water was responsible for cholera outbreaks. The British set about applying an engineering approach to cholera control — building sewers to separate waste and drinking water and protect potable water at its source — and it worked. But that experience encouraged British health authorities to fixate on cleanliness, above all else, as the way to healthiness. They saw the new vaccines as a distraction from the main game of carbolic acid and better drains.

The bulk of the second part of Foreign Bodies is taken up with the life of Waldemar Haffkine, the Russian-born microbiologist who developed vaccines against cholera and plague in the late nineteenth century. Haffkine, an obscure figure in the history of bacteriology who deserves better recognition, was hampered from the start by the fact that he was not a medical practitioner. Schama effortlessly places him in the scientific and social domains of the time, illustrating the inherent mistrust he faced both as a Jew and as a non-medico. (Pasteur was not a physician either, but his hagiography was unassailable by then.)

Most of the action takes place in the British Raj, where it soon becomes apparent that the outsider Haffkine’s vaccine rollouts relied more on local Indian support than on his colleagues in the British-run Indian Medical Service. Those vaccines probably saved an order of magnitude more lives than the British-sanctioned sector closures and slum clearances, but Haffkine suffered a blow in 1902 when nineteen people died as a result of a tetanus-contaminated vial of plague vaccine. Although he was exonerated five years later by an inquiry helmed by three giants of microbiology, his career had collapsed. Still only forty-two, he undertook no further significant work of discovery.

Haffkine would marvel at the new RNA technologies and the speed and scale of modern vaccine production, but he would understand the fundamentals of what has been hailed as a miracle of modern science. But this industrial-scale achievement has to be balanced with the more mundane (and at times uncivil) public health debates that preceded the availability of the Covid vaccines.

Uncertainty about something as basic as how SARS-CoV-2 is transmitted lingered longer than the time it took to produce the first vaccine. Masks were recommended after the virus was found to sometimes be carried on the air (airborne transmission, that is) not just in the air (droplet transmission). A proven means of preventing respiratory infections, hand hygiene, was adopted early by everyone but quickly dropped away when mask mandates came into force. You probably need both to prevent transmission and it is interesting to note that the vast majority of Australians’ infections occurred after masks disappeared and hand hygiene waned.

The web of life is a fragile gossamer. Subtle, undetectable disruptions in one part of the chain can lead to unexpected downstream consequences. Almost all new human infections are caused by pathogens that were once harmlessly confined to the animal world. The movement from animal to human is happening principally because of habitat loss, an increasing reliance on overcrowded food production and, sometimes, local tastes for exotic meats from undomesticated animals.

Foreign Bodies opens with the words attributed to Pliny the Elder — in the end, all history is natural history — and Schama finishes with the story of the decline of the horseshoe crab. Unchanged by evolution over millions of years, the crab’s blood has been used in recent decades to test for the presence of a specific contaminant in vaccine vials. Climate change and overharvesting have dramatically reduced the crabs’ numbers and pharmaceutical companies have struggled to find a more sustainable alternative at a time when safe vaccine production is an international industrial priority.

This is an unusual but beautifully written book. Schama admits it was not the one he was planning to write when the pandemic began. It is a mixture of personal observations of North American nature, modern political commentary, microbiological exposition, historical analysis, anecdote and biographical diversion. Occasionally, present-day issues jarringly appear in the midst of a prolonged historical narrative, and I wonder if Haffkine deserves as much space as he gets. But these are quibbles and I am grateful to Simon Schama for painlessly curing me of my Covid-19 avoidance disorder. •

Foreign Bodies: Pandemics, Vaccines and the Health of Nations
By Simon Schama | Simon & Schuster | $59.99 | 480 pages

The post Lady Mary’s experiment, and other infectious stories appeared first on Inside Story.

The interesting addendum to this parade of facts is the covert nature of abortion procedures. The number performed in Australia is nearly impossible to accurately calculate because no specific Medicare item number exists (the rebate is shared with that for miscarriage curettage) and only South Australia collects data on pregnancy outcomes. Medical abortions are even more difficult to numerically assay.

Think about those facts for a minute: it’s the third most commonly performed surgical procedure in Australia but nobody, anywhere, is analysing or even supplying accurate statistical information as to numbers, types or reasons.

I am a women’s health services provider, and we professionals are all in agreement: the most fundamental right of those with uteri is to have agency over their bodies, their lives, and the means and methods of personal choice in reproductive health. And yet a procedure that is swift and accessible has been legalised in Australia on a piecemeal, state-by-state basis, influenced by differing standards of acceptability based on geography and local attitudes.

Abortion is the secret obverse of motherhood, a choice rather than a sacrifice, and that makes people, especially right-wing male Christian politicians, uncomfortable. You could say that Australia’s abortion policy comes down to this: you’re welcome to have one as long as you promise not to talk about it.

Madison Griffiths’s memoir Tissue positions her squarely in the eye of the abortion discourse storm. She is a feminist, a vegan, a cis-queer artist and published essayist, a podcaster and a domestic violence campaigner. In the middle of the Covid lockdowns in 2021 she was confronted with a pink line on a test strip, undeniable evidence of her own pregnancy. What action she chose to take is, of course, at the centre of this narrative. Griffiths decided to have a medical abortion.

There are things we never find out about Griffiths’s choice. We do find out about her problematic relationship with her own mother and her mother’s anorexia, about the love between the pair, and about Griffiths’s considered intention to become the opposite daughter to the child her mother asked for and expected.

Griffiths puzzles her conservative mother, with her unshaven underarms and legs, her non-conforming clothing, her same-sex relationships and her drug use. “[W]hen I consider my own connection to my mother,” she writes, “there has always been, injected into every goodnight kiss, every tense phone call, a complex thread of guilt; the feeling of having failed, having committed a grievous wrong against her, having let her down.”

Griffiths accepts her mother’s anorexia without qualification, and there is a moment in Tissue that made me catch my breath in wonder: the comparison between the fat-melting cling wrap encasing her mother’s abdomen and the condom Griffiths’s lover refused to wear. Her lover “felt suffocated once fitted in a clear casing, their body robbed of glee. They too, were hungry. But unlike my mother or myself, their hunger mattered.”

Griffiths’s central and complicated relationship with her mother is never completely resolved, although ultimately she implies that the choice to pursue termination, to opt out of parenthood, has given their dyad a degree of resolution. She describes her mother’s love after the abortion as “urgent and keen to shelter me from scorn, determined that I not become her parody, for she is my mother, and I am hers to protect.”

Abortion is, at the core of it, about choosing or denying motherhood, a choice formed from past experiences that will echo into the future: the branch in the path, one course taken and the other unseen, unknown, unknowable. Implicit in Griffiths’s decision-making is the knowledge that she may well experience premature menopause, an inherited condition that heightens the chance this will be her only pregnancy.

But we learn more about her thoughts after the abortion than before, once the termination has been given personhood in its own right and discussed like a breathing individual, both in the abstract and the concrete. Ironically, though, by discussing the effacement of her body by the unwilling nourishment of a being whose existence she considers complete and separate, Griffiths avoids a journey to the latest frontier in the war against women’s bodies.

The battlefield is shifting from women’s reproductive rights to the joyless self-effacement of modern motherhood, misogyny’s newest and most sinister gift. It is no longer considered acceptable to mother in any other way than by the most arduous of labour. Griffiths mentions the Instagram moments of parenthood, a newborn suckling its mother’s breast, a proud father in the background. But modern motherhood is now a matter of continuous soul-obliterating attention to each child, broken sleep for years at a time, an insistence that a crying baby or toddler risks severe psychological harm.

Where Griffiths’s mother’s abdomen was “ripped open” by childbirth, Griffiths spared herself the agonies of parenthood, describing her abortion as “a celebration of my vibrant, colourful, beautiful life. A homage to my joy.” And yet, and yet… Abortion is seldom chosen lightly. Of the aftermath of my own abortion, I once wrote, “I was unbalanced I knew, filled to the brim and over with rage — pure, white, volcanic anger. What tiny chinks remaining were stuffed with grief.”

We never really get to see any great ambivalence in Griffiths’s account of her feelings and motives. It is possible that she genuinely saw her abortion as an unmixed blessing, but she describes an episode of short-lived sobriety afterwards, the creation of a Spotify playlist that reflected her decision, a playlist in which the word “baby” featured in the titles of a third of the songs, which seems to suggest that the impact was greater than she had expected, perhaps more than she was easily able to accept.

Griffiths’s words can seem like they were carefully selected to obscure rather than clarify, as though within the 200-odd pages of her narrative we are given Griffiths only in glimpses, a minnow in a deep, still pool seen in flashes and fragments rather than as a discrete and integrated whole.

This left me musing on the obligations intrinsic to publishing a deeply personal narrative. What portion of the author’s life and experiences do we have a right to expect? Can we find a way of listening without considering ourselves entitled to the whole gory story?

But there are moments that invite elucidation in this book: the incident, for example, in which Griffiths smeared the blood of her abortion over the toilet in her boyfriend’s share house then motioned to him: that’s your problem, clean it up. We never learn what was going through her mind, what her boyfriend’s response was. Her actions are left hanging, without expansion, without analysis. It seems a strange place to exercise coyness.

In rebuttal, one could argue that memoir is selective by its very nature. The author weaves a story from a series of small but significant incidents, moments that, taken together, illustrate and unpack a greater whole. But Griffiths has opened up only part of her tale, and this causes her book’s straddling of the divide between the personal and the polemic — both its greatest strength and its greatest weakness — to be uneasy.

Truly, in its looping, discursive, sometimes unfocused and repetitive recitations, Tissue parallels the conflicting thoughts and emotions Griffiths must have felt when attempting to make sense of the event during three months of late-night sessions in front of the screen: the real-time processing necessary to place a life, unlived by choice, into the past. As a reader, however, it made me wish that Griffiths had spent more time with an editor.

There were also prolonged discussions of the impact of Roe v. Wade in America, but conspicuous in its absence was any reference to Griffiths’s home in Australia, a country in which abortion is legal and the tablets Griffiths took to procure her abortion easily obtained. Again, I wondered where this discussion would fit into the range of Australian experiences, and whether her narrative could be considered as representative. Australia is filled to the brim with stories, other women, other men, other lives.

Perhaps the strongest of Griffiths’s themes comes in her chapter on queerness and unplanned pregnancy. While it is a fact that very few trans men or lesbians will ever require an abortion, perhaps the marginalisation of that tiny minority means a genuinely queer-centred discussion is long overdue, and Griffiths is ideally placed to begin that process. I found myself impressed by the chapter and, later, thinking hard about the issues it raises.

I have provided abortions; I have had an abortion. My daily working life is a study in abortion and its consequences, in foetal abnormalities, terminations after the most bitter and agonising of discussions, sleepless nights and tears blotted by tissues drawn from the box that sits always on my desk.

I have needed to face my anger and grief honestly, head on, and acknowledge that my choice to prioritise myself — the right decision then and afterwards — came at a significant cost. I have subsumed my pain, transformed it into a crucible, a map to something new, something better. The consequences of my loss have made me a more feeling person, tougher and more aware. Perhaps because of that, I am strongly inclined to respect abortion narratives, and I found much to respect in this flawed but energetic book.

Griffiths recites her feelings over and over, each iteration varying only in its minutiae, creating a strange and tangled web of deliberation, her body a citadel invaded by a barbarian horde, the cells of her unplanned pregnancy. She reads widely; she quotes impressively; and many of those quotes made my heart sing.

Though her story ultimately feels to me like a delta — more breadth than depth — Tissue contains moments of great beauty and clarity, sentences that had me gasping, hand over mouth, in which I felt seen. This book has a tremendous heft, a combination of muscularity and verve, and I came away from it with benefits that are likely to increase with time. •

Tissue
By Madison Griffiths | Ultimo Press | $34.99 | 320 pages

The post Eye of the storm 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. •

The post Will vaping reforms go up in smoke? appeared first on Inside Story.

Mind Medicine Australia, an advocacy group, was earlier knocked back when it sought to have the two substances legalised. On my reading, its bid had serious deficiencies: in particular, it cherrypicked studies rather than conducting a systematic review of all the evidence. In light of those problems, the TGA commissioned its own review of the evidence. The findings appear to have convinced the decision-makers that allowing limited access to the two substances is justified. In effect, the TGA took this decision on its own motion, offering an interesting case study of delegated authority.

The decision removes therapeutic uses of psilocybin and MDMA from Schedule 9 of the Poisons Standard, which includes heroin, crystal meth and other illicit drugs, and places them on Schedule 8, alongside medicines — opioid pain relief and ADHD treatments, for instance — to which access is heavily restricted. Australia has an inconsistent patchwork of state and territory laws governing illicit drugs, but they all refer to the Poisons Standard, which is administered by the TGA. This puts the TGA in an unusual position: at a stroke, a committee of clinicians and bureaucrats was able to rewrite drug laws across Australia. But it also means the decision was based on clinical and scientific evidence rather than the feverish law-and-order politics that dominates “the drugs debate.”

Some degree of backlash was inevitable. In an opinion piece for the Age, psychiatrist Patrick McGorry and two academic colleagues shared their concern that the benefits of these treatments haven’t been shown to outweigh the risks. Trials to date, they point out, have excluded participants with psychosis, eating disorders, substance use issues and other medical conditions, limiting them to people with the smallest possible risk profile. This means that we can’t extrapolate the likely effect of these substances in real-world practice. McGorry and his colleagues also note the lack of evidence on the long-term effects of the two substances’ use.

But the TGA’s decision is more limited than many commentators realise. It has approved the therapeutic use of these drugs without approving specific products containing them — and the pathway for accessing unapproved products is tortuous. A psychiatrist must apply to a Human Research Ethics Committee for permission to use an unapproved drug with human patients. Permission is only given for serious or life-threatening illness where no approved medicine can do the job. We are talking about severely unwell patients who have already tried everything in the medicine cabinet without any relief.

The psychiatrist must also provide evidence that the potential benefits outweigh the risks, and outline how they will manage any harms. In short, using psilocybin and MDMA in clinical practice faces exactly the same checks and safeguards as McGorry and colleagues must meet in their own clinical trials on psychedelic-assisted psychotherapy.

Most people with severe illness are going to fall at the first of those hurdles. Finding a psychiatrist is extremely difficult; demand far outstrips supply, and the cost of private care is eye-watering. It is going to be even more difficult to find a psychiatrist willing to apply to become an authorised prescriber of otherwise-illicit drugs. Psychiatry is a conservative profession, and it primarily views recreational drugs as a risk factor for mental illness rather than a potential therapy.

A psychiatrist who does become an authorised prescriber must then find a “sponsor” — a pharmacist willing to synthesise psilocybin or MDMA. Given Australia’s patchwork of drug laws, this is not entirely risk-free for the sponsor, even when the drug is intended for therapeutic use. Medical researcher Stephen Bright estimates the cost of experimental treatment with these substances at $20,000 per participant, accounting for study costs (including expert personnel), the substances themselves, and inpatient treatment. Faced with these barriers, many people with PTSD or severe depressive illness might contemplate accessing psilocybin or MDMA informally — outside of an experimental trial or the psychiatric pathway.

The criticism I’ve seen from psychologists is that the TGA has acted on data from phase two studies, which investigate the safety of a substance in human subjects, without waiting for more data from phase three studies, which estimate its efficacy against a given condition. There are two separate issues here: risk and uncertainty. We know the substances are, broadly speaking, safe to use under controlled conditions, but there remains uncertainty about how effective they might be. Experience teaches us to be cautious on that front: promising treatments like ketamine infusion have turned out to have profound but relatively short-lived effects on severe depression, giving people hope that was yanked away when experimental trials ceased.

That said, the TGA decision is consistent with the principles outlined for the unapproved products pathway. These state that the requirement for evidence is lowest when the need is greatest. In case that sounds counterintuitive, think of a patient facing death from an aggressive illness; beneficence suggests letting them consent to an experimental treatment, even if all it offers is hope. The TGA has recognised that people currently suffering with severe and untreatable mental illness are in a comparable situation. Hope is thin on the ground, and the potential benefit outweighs the relatively well-known risks of harm.

Much of our knowledge of these substances comes from informal use rather than experimental studies and clinical trials. This is knowledge that circulates via the “cultures of care” — a term coined by Australian HIV researcher Michael Hurley — that surround recreational use of these substances. Drug users have developed and actively share information and practices intended to minimise the risk of drug-related harms, including judgements about safe doses and titration, creating a safe environment, guiding a person through a “trip,” watching for overdose, and maintaining a safe pattern of use.

Psychiatrists and counsellors may find themselves working with depression and PTSD patients who are exploring informal use of these substances. Both groups may need to familiarise themselves with harm-reduction principles and strategies.

The TGA decision highlights something important for people interested in the debate over how to legalise or decriminalise the use of an illicit drug. Medicalising their use is one possible strategy. When the TGA proposed banning “poppers” — small bottles containing volatile alkyl nitrites for inhalation — I led an advocacy campaign arguing these products were the only way for many men and other queer people to have safe and comfortable anal intercourse. The TGA listened to our arguments and left the most common ingredient in poppers on Schedule 4, available for prescription by doctors.

In doing so, the TGA demonstrated a willingness to listen to communities speaking from expertise gained from decades of informal use of the substances in question — a willingness that may have played a role in its subsequent decisions on psilocybin and MDMA.

In most cases, though, securing legal permission for therapeutic use only benefits people with the resources to access specialist medical care. We have seen this with medicinal cannabis in Australia: people using approved products are paying hundreds of dollars each month for the privilege. People who can’t afford this treatment continue to use cannabis products from informal suppliers and remain vulnerable to policing and prosecution if they are caught. Medicalising illicit drugs reproduces what medical researcher Julian Tudor Hart called “inverse care law,” where medical care is hardest to access for those who need it the most. •

The post A frolic of its own appeared first on Inside Story.

Although they may not have reached these heights of nihilism, many people do wish their lives would end, or at least that they could be cut short if they became unbearable. With assisted dying increasingly in the news, Caitlin Mahar’s new book, The Good Death Through Time, presents an enlightening history of the desires of people suffering from terminal illness or planning for a dignified ending, and of the cultural shifts, religious values and medical advances that have shaped, supported or obstructed them.

Before acquiring its more familiar contemporary meaning about 150 years ago, euthanasia simply meant a good death. Dying was seen as a spiritual ordeal to be endured with Christian patience, and thus a test of courage and character. Much emphasis fell on what came after death — salvation or something much worse — rather than its attendant agonies. “For the faithful,” Mahar writes, “a good death was marked by the embrace or overcoming of suffering rather than its elimination.”

Just as well: doctors at the time had no power to alleviate pain. In fact, they believed it was beneficial to health, and were more apt to cause than cure it with their treatments. In any event, preparing the soul for death was judged more necessary than dulling the mind.

Some of this changed in the mid nineteenth century with the advent of opiates and other anaesthetics, prompting the earliest medicalisation of dying. Euthanasia came to refer to deaths eased by a physician’s care with the aid of narcotics. Pain was increasingly seen to lack redemptive qualities; reducing it might even help the dying to focus on spiritual matters. Mahar argues that this shift in attitudes reflected a more general rise in people’s dread of suffering and sensitivity to discomfort.

That rise, which William James characterised as a “strange moral transformation,” drove campaigns to reduce needless pain by outlawing vivisection, corporal punishment and blood sports. But it also provoked a backlash that foreshadowed present-day sneering at thin-skinned progressive “snowflakes.” A British critic of the voluntary euthanasia movement in 1906 ridiculed it as the home of pain-averse “literary dilettanti” and “neurotic intellectuals,” a charge later echoed by an opponent of euthanasia legislation who worried “we were getting too soft as a nation and too sensitive to pain.”

Mahar offers a compelling account of the rise of British voluntary euthanasia activism in the 1930s, a movement that originated within the medical profession and aimed to give doctors the power to accelerate lingering deaths using morphine and other narcotics in strictly limited circumstances. Despite having eminent supporters such as George Bernard Shaw and H.G. Wells, legislation failed after opponents raised concerns about the potential for abuse by relatives, slippery slopes, medical overreach, and the challenges of regulation.

The revelation that the Nazi regime euthanised well over 100,000 disabled people further damaged the voluntary euthanasia cause, reversing prior support within the medical community and undermining public support for the idea that some lives are “not worthy to be lived.” Mahar shows how eugenics-inspired advocacy for involuntary euthanasia of the intellectually disabled — advanced in Australia by University of Melbourne anatomy professor Richard Berry, whose name was permanently scrubbed from a campus building in 2016 — has tarnished the voluntary euthanasia movement.

The Good Death Through Time provides an authoritative examination of euthanasia debates, court cases and initiatives from the 1950s to the present. Mahar identifies shifts in the groups viewed as suitable for euthanasia, including people on life support or in unrelenting pain not linked to a terminal or incurable condition, as well as in the rationales offered for the practice. Although reducing suffering remains paramount and fear of pain may paradoxically have grown with medicine’s rising capacity to palliate it, voluntary euthanasia has been framed increasingly as a matter of rights, dignity and personal empowerment rather than alleviation of distress.

Australia has been near the forefront of legislative developments. Advocates for voluntary euthanasia argue that overly narrow eligibility requirements have led to unnecessarily bad deaths for those excluded. Disability activists, on the other hand, caution against broadened criteria, citing the Dutch experience of rising euthanasia among people with dementia or mental illness. Mahar concludes with a concise epilogue covering this recent context.

The Good Death Through Time is a lucid and well-documented guide to a challenging topic. Mahar provides a sympathetic but clear-eyed picture of euthanasia’s many protagonists and perspectives without forcing a single view onto the reader. The scholarship is global, but the focus on Australia and Britain adds to the book’s local relevance.

Mahar’s work is especially compelling as an account of the medical profession’s role in euthanasia, in all its meanings. The profession’s views on the desirability and scope of euthanasia have waxed and waned, its pharmacological tools enabling the practice while altering popular attitudes and increasingly pathologising pain. There is no better guide than this one to the wider context of current debates about assisted dying.

Philosopher Dean Rickles’s Life Is Short approaches death from a quite different angle, though he would agree with proponents of voluntary euthanasia that how we fashion our lives and deaths should be a profoundly personal choice. In re-visioning Seneca’s On the Shortness of Life, he wants to persuade us that although we may dread the end of life and entertain fantasies of eternal youth and immortality, it is life’s finitude that gives it significance.

“To have a meaningful life,” he writes, “death is necessary.” Only by having and recognising limits — “the very stuff of meaning” — can we make purposeful choices to create our selves and realise our futures, rather than being tossed around by life.

Life Is Short takes this idea and runs with it through eight brief but somewhat meandering chapters. Rickles suggests that the desire for immortality, or even just for a longer life, is often driven by a reluctance to foreclose future possibilities by making hard choices in the present. He dissects the difficulties individuals face in dealing with our future, notably temporal myopia — discounting the future relative to the present — and the less familiar but no less destructive favouring of the future at the present’s expense.

The key to overcoming these “diseases of time,” he suggests, is to develop a strong sense of connection with one’s future self rather than seeing it as a stranger. “[O]ur present self just is the future self of our past self! Treat every future time as equally as Now, because it will be Now later, and it will be your Now.”

How we should go about making a more meaningful life comes down to making it a project (“Project Me”), carving out a future by choosing and acting rather than leaving options forever open. Doing this requires us to overcome the sense that life is provisional and not yet quite real, which Rickles dubs “onedayism.” That process of overcoming involves understanding ourselves and our motives better. We must move beyond the childish feeling of being unbounded and invulnerable to a mature commitment to a purposeful life and work, dull as that may sound.

Despite his general breeziness and references to contemporary popular culture, Rickles’s intellectual influences have an oddly mid-twentieth-century flavour. Existentialist writers (Sartre, Camus, Heidegger, early Woody Allen) get guernseys, with their ruling image of solitary individuals creating heroically authentic selves against a backdrop of cosmic meaninglessness.

Carl Jung takes centrestage in the book’s second half; not the kooky, occult Jung of mandalas, the collective unconscious and flying saucers but the wise Jung of personal identity and the process of maturation. Rickles discusses at some length Jung’s ideas about individuation — the development of a coherent self through understanding our unconscious motivations — and how the archetypes of the present-oriented child (Puer) and the prudent elder (Senex) shape how we age.

What is noteworthy about this cluster of ideas is not just how much they have been generationally cast aside, but also how they portray our orientation towards life and death as fundamentally lonely and stoical. To Rickles, the authentic, unprovisional life is one in which individuals exercise their will by making resolute choices, pruning the branches of their tree of possibilities, and committing to a specific future.

There isn’t much room for other people in this vision of autonomous self-creation. They tend to figure primarily as the conformist horde who stand in the way of us becoming authentically ourselves by tying us down with their norms and expectations. Yes, each of us exists as a solo being with a unique beginning and end, but something is missing in an account of life’s meaning when relationships and social life are so apparently incidental.

It is well worth spending one of the last thousand or so Saturday afternoons we have left on Life Is Short, but in some ways it is an odd book. Contrary to its subtitle, it offers few concrete prescriptions for living a more meaningful life, so it is not a self-help book, however highbrow. Despite the amiable, self-disclosing persona of the author, its level of abstraction is too high for it to be accessible in a de Bottonian way, although Rickles sprinkles it with some memorable epigrams (“death anxiety is the ultimate FOMO”). Its intellectual style is too associative and wandering to be a philosophical treatise on the nature of life’s meaning.

All the same, as a meditation on a very big question — perhaps the biggest of them all — Life Is Short achieves its goal of making us think about the unthinkable. •

The Good Death Through Time
By Caitlin Mahar | Melbourne University Press | $35 | 256 pages

Life Is Short: An Appropriately Brief Guide to Making It More Meaningful
By Dean Rickles | Princeton University Press | $34.99 | 136 pages

The post Appointment with death appeared first on Inside Story.

Mental health professionals mostly condemned the change. “Just as people shouldn’t be asked to ration vital medicines like insulin,” said the Australian Psychological Society, “they shouldn’t have to ration mental health care.”

But one expert stood against the trend: Ian Hickie, co-director of Health and Policy at Sydney University’s Brain and Mind Centre, who has been a persistent critic of the scheme.

Hickie is a go-to commentator on matters of mental health in Australia. Yet news outlets turning to him for comment rarely acknowledge he has a stake in the debate. He was a co-founder of Headspace, a federally funded network of mental healthcare hubs for young people that competes with private practices for trained staff.

Commenting on the Better Access cuts, Hickie complained that Headspace “had lost a third of its skilled workforce to the private sector over the last three years.” He called for the government to fund more places for clinical psychology graduates and to “deploy” the extra graduates to work in rural and regional areas.

Headspace serves people aged between twelve and twenty-five. But the federal government may be considering a Headspace-style approach to adult mental healthcare, with publicly funded care provided by staff based at “hubs” around the country. This would solve many of the agency problems that affect quasi-markets for care like Medicare and the National Disability Insurance Scheme. In its role as overseer of these markets, the government has no direct control over what services are provided and where practitioners can work from.

This is an important debate — yet a key voice has gone missing. All the commentary on the Better Access debate has come from people who research and treat mental illness; we haven’t heard from the people most affected by the changes, people living with mental illness.

I have been living with serious mental illness for more than two decades. In a recent essay for Meanjin I described my decision to come out about living with an alphabet soup of mental illness: ADHD, bipolar type 2, complex PTSD. I manage these conditions alongside my career and my PhD studies in regulation and governance.

This challenge isn’t uncommon: up to 3 per cent of the adult population are living with bipolar disorder. But you almost never hear from people like me — people with serious mental illness — in media coverage of mental healthcare.

For this, I blame the mental health sector itself. It uses the term “lived experience” to describe (and arguably, to contain) the perspective of people with mental illness. But there are few mental health organisations that engage with the mentally ill community as a community — building our potential to advocate on our own behalf.

Many mental health organisations are purely service providers, offering programs and services to people conceived solely as service users. That’s why you’re not hearing about the likely impact of the Better Access program changes from the people most likely to be affected.

Here’s how I am affected by those changes. A few months ago I was in a really sticky place with my mental health. Sticky in the sense of being stuck, but also because it was sticking to everything: my dating life, my family relationships, my work, my PhD study, the lot.

I work for a community service wage, and on top of that I pay the mental health tax — psychiatrist fees and the cost of off-label medication. I would struggle to pay for private care at $150-plus per session.

I’m part of the client group identified by Jillian Harrington as needing extra care to make progress: people with developmental trauma or (as it is also known) complex PTSD. As I wrote on my blog:

In the original Latin, complex meant interwoven. For me, it’s not just the ongoingness of (childhood) trauma that produces complex PTSD; it’s the fact that the trauma becomes part of your personhood. The traumatic experience forms you as a person. Thus, treating cPTSD is fundamentally difficult: it involves changing your whole way of being in the world, not just treating symptoms or modifying unhelpful patterns of behaviour.

And this is doubly difficult because of the fact of interbeing — our personhood is constituted in and through webs of relationship with other people, animals, objects, places, structures, and rituals. Changing yourself is hard when these webs of relationship remain in place and unmodified.

In the aftermath of last year’s “menty B” I started a program of care with a counsellor in private practice who uses a range of cognitive therapies to support clients with the needs I identified. In particular, my goal was to develop skills for getting out of periods of intense distress before I burn out or break down. Twenty sessions is enough to tackle that goal.

I’ve done extended periods of counselling when I was earning more and I could pay out of pocket. I know that I can bring a particular problem to a counsellor and work with them to build the skills I need to deal with it. Bit by bit, brick by brick, I build up my boundaries against the kind of situations that have historically placed my mental health and stability in jeopardy.

The Better Access program means I pay about $50 out of pocket for each session, which I can afford. But the changes in the program mean I will have only ten sessions this year before I have to pay $150-plus per fortnight to continue in care — and that I can’t afford, living in Sydney, in a cost-of-living crisis, on a human services wage.

As psychologist Jillian Harrington reports, the Better Access evaluation studies suggest that psychologists targeted increased access to care to those who needed it most. This meant the scheme didn’t function as a bandaid for pandemic stress, anxiety and depression, the way the previous government may have hoped it would. It functioned exactly as a public investment should: it was targeted towards those most in need — people with chronic, long-term, ongoing, serious mental illness.

The implicit debate between the Headspace and Better Access service models is similar to the fight over funding for primary health and emergency care provision. It poses the question: should mental healthcare be distributed throughout the community, the way general practice is, or located in centralised hubs, the way hospital care is?

Is mental illness like a broken arm (favouring centralised hubs) or like a chronic illness (favouring distributed provision)?

When I put it like that, observant readers will object: obviously, it’s both.

Sometimes we need acute specialist care and sometimes we need regular doses of care for ongoing illness. Sometimes we need care for the disorder itself and sometimes we need support addressing life issues that are aggravating the disorder.

We need a publicly funded system of care that does both, not a fight over one solution or another. •

The post Mental breakdown appeared first on Inside Story.

China was the last country to pursue a zero-Covid policy, and its reversal poses an important question: when can we say an epidemic is over?

If social media trends are anything to go by, the answer is “not yet.” The hashtag #CovidIsNotOver is still doing solid numbers. A vigorous movement is calling for a return to #ZeroCovid, including mask mandates and lockdowns. One key “Zero,” Burnet Institute head Brendan Crabb, recently described Victoria’s Covid policy as “pro-infection.”

The tone is passionate, often verging on hyperbolic and occasionally crossing over into outright toxicity. An opinion piece by Broome physician David Berger suggests only the Zeroes perceive or indeed care about the ongoing harms of Covid.

The Zero discourse is framed in two ways. The first is a justice claim: that the pandemic is not over until and unless we fully protect the most vulnerable people in society, particularly people with frailty, disability or chronic illness that increases their risk of severe illness and death from Covid-19.

The second frame rests on the risk of long Covid, which can strike people who are young, healthy and otherwise non-disabled. Advocates of this frame claim that repeated Covid infections increase the risk of long Covid, which means that everyone should be doing everything in their power to avoid exposure.

As a public health practitioner I have a lot of time for the first frame and serious doubts about the latter. It’s clear that our state and federal policy of “learning to live with Covid” privatises the risk of severe illness for a significant minority of the population. People in this group can only do so much to protect themselves.

We need to have an honest conversation about the sacrificial logic of “living with Covid” and its implicit view that the convenience of the many outweighs the right of the few to life itself. Although commonly described as “eugenics,” this policy is less about who gets to reproduce and more about necropolitics — governmental power and policymaking over death and dying.

The difficulty here is that “ought implies can,” and we just don’t have strategies to reliably protect vulnerable people from exposure, infection, serious illness and death. As China demonstrates, highly infectious strains like Omicron can circulate even amid aggressive lockdown and quarantine practices.

Studies of mask use in the real world, meanwhile, show relatively modest efficacy — nothing like the efficacy rate assumed in modelling studies. To reduce the risk of severe illness in immune-compromised people we may need better vaccines and widespread pre- and post-exposure strategies using monoclonal antibodies, antiviral medication and other treatments.

That said, one of the biggest causes of excess deaths from Covid-19 is the failure to fully vaccinate. Most people benefit from vaccination — including many people conventionally described as immune compromised. (Covid vulnerability is concentrated among people on B-cell depleting therapies.) Victoria’s chief health officer reports that 40 per cent of recent deaths occurred among the 2 per cent of the state’s population who are wholly unvaccinated.

Many of the remaining deaths, particularly among the elderly, involve people who have not received boosters. Booster provision remains stubbornly slow in Indigenous communities, particularly in remote and regional Australia. We are not making the most of the proven protective strategies available to us.

This is where many Zeroes lose me. In their efforts to promote renewed mask mandates and lockdowns, some have chosen to call vaccine efficacy into question. Given the clear evidence that full and up-to-date vaccination is highly protective against severe illness, it’s hard to imagine a more dangerous rhetorical strategy.

These Zeroes claim that vaccines don’t work because they don’t prevent infection. Yet vaccines were designed and tested for a completely different purpose — not to prevent transmission but to reduce the risk of severe illness once infection has occurred.

This doesn’t reflect a lack of ambition on the part of vaccine designers. They took this approach because the evidence shows that coronaviruses as a family can easily evade immune defences against primary infection — which is exactly what we’ve seen with the Omicron strain. The ongoing transmission of Covid-19 is evidence vaccine designers got it right.

Calling vaccine efficacy into doubt serves to stoke fear of Covid infection. In a sense, the zero-Covid debate reflects a disagreement about the pragmatic value of alarm — whether it is useful for the general public to perceive a continuing sense of crisis. This is what that second frame comes down to; it suggests that everyone should perceive themselves as being at continued risk from Covid-19. And here I would point out that alarm is not a renewable source of energy.

It’s helpful to distinguish between the end of the pandemic and the end of the crisis. Crises end when we collectively and implicitly decide they are over. As the American economist Anthony Downs’s theory of the issue-attention cycle suggests, these decisions reflect patterns in media coverage rather than trends in scientific data. The theory predicts a drop-off in attention as people acclimatise to pandemic life and, in particular, once people come to believe the problem largely affects a numeric minority.

I’ve been through this once before with a different epidemic — the HIV/AIDS crisis. In the mid 2000s many people assumed the advent of effective HIV treatments meant the crisis was over. Almost overnight, prevention practitioners went from being seen as heroes in a valiant battle to being considered failures for not preventing continuing transmission.

Covid policymakers have undergone a similar humiliation. Early in the crisis Australia picked a policy of flattening the curve, postponing the bulk of infections until the health system was prepared to cope and vaccines had become available. Although it wasn’t without significant problems, including the slow rollout of vaccines under the previous government, this strategy was for the most part a resounding success.

But the zero-Covid movement seeks to move the goalposts, redefining success as the prevention of transmission altogether. They depict a successful strategy as a failure, or worse — as “pro-infection.”

A way does exist for describing what an end to the pandemic would mean in biological and epidemiological terms. It would happen if three conditions are met:

1. A new variant causes relatively mild disease.

2. The variant is highly infectious and therefore outcompetes other variants that cause more severe illness.

3. Infection with this variant generates enough immunity to stop people from getting it again within the space of a year or so.

If these conditions were met, the experience of Covid-19 would become just like the experience of cold and flu. In effect, Covid-19 would become just another coronavirus among the many that circulate globally and locally.

Omicron meets criteria #1 and #2, but whether it meets the third criterion is still an open question. The Zeroes mobilise plenty of anecdata about people getting Covid six weeks after their last bout; but prior infection clearly does confer some degree of immunity for some time — it’s just not clear how much or how long. While we wait for more data, based on the justice claim and the epidemiology I have to conclude that Covid-19 is not yet over — but the sense of crisis has certainly passed.

We may never end the incidence of Covid-19, but we have proven our ability to reduce its impact. To succeed fully in this strategy, we must also protect groups of people who are more at risk of severe illness. We need to be clearer about which groups are actually at risk — it’s not everyone with immune deficiency or disability generally. We need scientific advances in vaccines, monoclonal antibodies, and antiviral medications, not to mention development of more sensitive rapid antigen tests. But we might also need to accept changes in our everyday way of life that are intended to reduce the risk to people we know and love. •

The post Means to an end appeared first on Inside Story.

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. •

The post An ounce of prevention… appeared first on Inside Story.

The medics’ response was all about the politics of knowledge: the ferocious battle over who counts as an expert and what methods can generate reliable claims. The person at the heart of the debate was Margaret Faux, a nurse turned lawyer who runs a medical billing company and has completed a PhD using qualitative methods to examine how doctors learn about billing. It’s hard to imagine a better vantage point for commenting on the vagaries of Medicare billing arrangements. But the joint investigation by the ABC and Nine newspapers presented Faux as its authority for the blunt claim that a quarter of Medicare expenditure, or $8 billion, is “leaking out of the system we all rely on.”

Ferguson interviewed Faux for the segment in front of a giant screen onto which pages from her PhD thesis were projected. “Dr Faux estimates $8 billion is lost each year to the Medicare budget due to fraud, error and over-servicing,” says Ferguson in voiceover. Viewers could be forgiven for assuming that this is what Faux found in her thesis, but all we see Faux herself saying is: “The bottom line is, we don’t know exactly how much is fraud, deliberate abuse, and how much is errors.”

As others have pointed out, the $8 billion figure doesn’t appear in the thesis. Faux’s research addressed a related but different issue: how doctors in hospitals and general practice learn about Medicare billing practices. Her thesis cites a 2012 estimate of annual noncompliant billing of between $1.2 billion and $3.6 billion but does not itself investigate this quantitative issue. Faux’s recent estimate that fraud and error cost Medicare $8 billion was not part of her careful PhD research, but 7.30 viewers were left thinking that it was.

Inevitably, the resulting debate focused on the merits of the PhD rather than the issue at hand. One doctor argued Faux’s thesis didn’t count because its author was not a medical doctor. The president of the Australian Medical Association, Steve Robson, went on 7.30 to dismiss the PhD and was forced, on air, to admit he hadn’t actually read the thing. Many argued that qualitative research can’t cast any light on the merits of a quantitative approach to billing and fraud detection. Karen Price, president of the Royal Australian College of General Practitioners, issued two tweets (since deleted) denying that qualitative research could generate any useful findings at all.

Many doctors wanted to have it both ways, attacking Faux and the credibility of her work while selectively quoting from her thesis, which offers much to support their case that billing is confusing and enforcement capricious. Indeed, the central argument of the thesis (stated on page 10) is that it is not possible to estimate how much of Medicare billing is fraud — in the criminal sense — because fraud assumes that billers understand the regulations and deliberately breach them, whereas most medical practitioners “have never been taught how Medicare works or how to bill correctly at any point in their careers, and the so-called ‘rules’ of medical billing are highly interpretive and deeply opaque.”

That’s true: Medicare billing is a complex system. That’s not the same as saying Medicare regulations are complicated. Complexity results from patterns that aggregate out of subtle differences in how Medicare items and billing rules are phrased. This, for the record, is why qualitative research can shed light on quantitative patterns within complex systems. Faux’s research concerns the possibility of estimating and proving billing fraud. The question is not simply “how much fraud is there?” but “is it possible to estimate the fraudulent billing rate at all?”

For some years I was involved in a project using qualitative and network-analysis methods to see whether “thin markets” could be detected and fixed in the National Disability Insurance Scheme. Thin markets occur when there is too little competition to generate enough supply (a lack of market sufficiency) and too few different approaches to service provision to create real choice for consumers (a lack of market diversity).

Our research used network analysis to visualise how many discrete markets — markets producing one kind of service for one kind of need — the National Disability Insurance Agency oversees across all its regions. The NDIA sits astride a mountain of data on service provision, but it wasn’t making any of that data available to researchers or advocates. So people with disability were vulnerable if thin markets emerged undetected when disability service providers targeted lucrative niches. We examined survey data on service provision to see if we could identify potential “signals” to identify thin markets from afar.

During this project I presented my work visualising the NDIS market structure to a senior executive in disability policy. He’d been a lawyer for the Australian Competition and Consumer Commission, which has a four-point test for assessing whether competition is lacking in a given market. You’d just use the same test, he reckoned.

But there’s a world of difference between a complaint-responsive agency that already knows which market it’s investigating and a central agency, like Medicare or the NDIA, that oversees tens of thousands of markets and doesn’t know which ones it needs to investigate. GPs can look at their own practice and think “it would be easy to establish that my billing practices are legitimate,” but if you’re Medicare, sitting atop data on millions of care encounters each year, it suddenly looks very hard indeed. You have to look for trends that generate signals that are only partially reliable as indicators of fraud.

Investigation requires major human resources. The Medicare regulator, the Professional Services Review, investigates about one hundred practitioners per year, or 0.07 per cent of Australia’s 150,000 health practitioners. Yet Medicare sends out thousands of letters, placing the onus of proof on practitioners to justify their billing practices or face losing their practice or even their careers.

In other words, much of Medicare’s enforcement activity is little better than robodebt: sending letters with scary consequences based on statistical signals. If I were a medical practitioner responding to the ‘leakage’ debate, I would be using Dr Faux’s research, not seeking to discredit it. I would also be asking how much income is lost to under-billing — a common practice where rules are unclear or enforcement action is heavy-handed — and how this contributes to doctors ceasing to bulk bill or leaving general practice altogether. After all, that was the debate we were having before the “Medicare rorts” coverage came along.

Faux may have imagined that teaming up with investigative journalists would be a productive way to put Medicare leakage on the policy agenda. But investigative journalism has fixed cognitive and cultural framings: it goes looking for someone to blame for corrupt or criminal conduct. It is not well suited to the careful interrogation of complex systemic issues like those her own thesis was seeking to highlight. •

The post Faux scandal appeared first on Inside Story.

Those were the days before mobile phones, when doctors still carried pagers that beeped whenever they were needed. Sleep-deprived and stressed by the onerous workload, my heart rate soared every time my pager sounded, its insistent beeping a reminder that I was, in essence, in servitude to the hospital’s consultant medical staff, nurses and patients. My time was never my own.

One weekend, in an effort to provide me with a much-needed afternoon nap, my visiting boyfriend wrapped my beeper in aluminium foil and placed it in a metal tin to prevent it from receiving a signal. It would have been much simpler to turn the awful thing off but I, in my befuddled state, had refused to do so.

In The Doctor Who Wasn’t There, a history of technological innovations in medicine, Jeremy Greene, medical historian and practising physician, devotes a chapter to the development of the medical pager, which he aptly labels The Electronic Leash. The pager was made possible by FM radio technology and marketed by Motorola and similar corporations in the 1960s as a modern tool to streamline a doctor’s professional life.

Just like the telephone before it, the pager proved a double-edged sword: greater connectivity meant more flexibility — a doctor could be out at a barbecue and still contactable if a patient took a turn for the worse — but also more accountability. If a doctor could be contacted then he or she should be contacted.

This is one of Greene’s recurring themes: the greatest enthusiasm for novel medical technologies was often on the side of those who stood to gain financially from their widespread adoption. Doctors, among the supposed beneficiaries, were usually more gimlet-eyed, not only about the extra demands this new technology might place on them, but also about how it might interfere with the doctor–patient relationship. “The medium of care is always contested by different parties with very real professional, political, and financial stakes at play,” Greene writes:

The source of contention has always been an exchange about technology and power. In the name of empowering the consumer of healthcare, technologists present their new platforms as essential passage points for the future of medicine. In the name of defending the humanity of the patient, physicians assert that no technology should displace the doctor from the bedside.

Again and again, Greene tells us, this tension played out with new technologies. Both entrepreneur and doctor viewed each innovation as having subversive potential. Those who stood to gain financially from the widespread adoption of whatever they were spruiking — the pager, wireless monitors, closed-circuit television clinics, the electronic medical record — saw only the benefits of this subversion: better access to information for health professionals, better quality care for patients.

One of the towering mid-twentieth-century figures in this debate was Vladimir Zworykin, vice-president for research at the Radio Corporation of America and, later, founder of the Center for Medical Electronics at the Rockefeller Institute. Zworykin championed a number of innovations, among them the mainframe computer. As well as seeing the computer’s potential to store all manner of medical data, he envisaged a day when the computer would become integral to the doctor’s interaction with patients.

“Zworykin insisted that the fundamental relationship between doctor and patient would only be enhanced, never degraded, by the presence of the computer in the clinic,” writes Greene:

In 1962, he asked an audience of physicians to imagine a typical medical clinic fifty years in the future, in which physicians were freed of asking the same questions, conducting the same physical exam over and over again, since a standard history and physical would be automatically performed by a human–machine interface. In the year 2012, he predicted, any “Mr Jones” stopping by Middletown Clinic for his annual check-up would see the computer before he would see his doctor.

But doctors were conflicted, and sometimes their concerns were motivated by self-interest. “Physicians believed that telephone, radio, television, and computer all enabled an extension of their professional authority,” writes Greene, “but worried they could also lead to loss of control of the conditions of their own labour, or, worse yet, might open up the private spaces of the profession for new forms of public critique.”

It wasn’t only the medicos who saw the potential downsides of an increasingly wired-up clinic. Much of the development in the field took place during the cold war, when concerns about tracking and surveillance were rife. Fast-forward to 2022, when, as Greene writes:

One out of every five US employers that offered health insurance in 2018 collected wireless physiological information from the wearable devices of their employees… Many firms now use Fitbits and Amazon Halos and other wearable sensors not just to monitor the health of their workers but also to optimise their daily work routines — and dock their pay for bathroom breaks.

Greene has meticulously researched his subject: his bibliography runs to more than forty pages. What’s more, he’s succeeded in creating a fascinating narrative from what might have been a very dry history of wires and batteries. I suspect he might himself be a gadget enthusiast, much like one of the book’s principal personages, Norman Jeff Holter, the cardiologist inventor of the Holter heart monitor, which is still widely used today. Holter’s electronics laboratory had its origin above the family grocery store, and I can imagine Professor Greene holed away in his backyard shed on weekends, happily tinkering with circuits.

I’m not a Luddite but neither can I claim to be particularly tech-savvy; still, my interest was piqued by such things as the incredibly useful spin-offs of the humble telephone: the miniature telephone, which eventually became the hearing aid, and the telephone-probe, distant cousin of our contemporary diagnostic ultrasound.

The Doctor Who Wasn’t There was partly written during the pandemic, when telehealth was the top-of-mind medical technology for healthcare workers. While the telehealth industry was already attracting substantial corporate investment in the United States before Covid-19 came along, it was still in the early stages of implementation. The sudden onset of widespread lockdowns in 2020 saw the health workforces of the United States and many other countries — those that were digitally resourced — rapidly pivot to this mode of service delivery.

Inequities quickly emerged. Reflecting on his own experiences of working in a community clinic in East Baltimore, Greene writes:

In my first full month as a telepractitioner, not a single African American or Latino patient was able to successfully access the full telemedical suite in my clinic sessions… Similar challenges of equity in access to telemedicine were reported in community health centres and other primary care practices in Philadelphia, New York, and Boston. Video visits were repeatedly found to be less common in telemedical encounters among Black and Latino patients, and in households earning less than $50,000 per year.

This pattern of inequitable access to novel technologies is another strong theme of Greene’s history. In 1971, for example, a physician in Boston built a microwave link connecting a remote urgent care clinic to the emergency room of Massachusetts General Hospital, and federally funded demonstration projects for similar technology were set up in Harlem in New York, on the West Side of Chicago, in rural Vermont and New Hampshire, and on Native American reservations in Arizona. In the end, though, these technological experiments in disadvantaged communities fizzled and died when interest turned to some other emerging technology.

I was working at a metropolitan Headspace centre during the pandemic and found my young patients to be very comfortable with video consultations so long as they had a private space in which to talk. One of the common healthcare barriers for young people is physical distance and lack of good transport options: with the click of a mouse, telehealth removed this obstacle. But my experience was not the norm in Australia. As a recent nationwide survey of telehealth services during the pandemic found, people with disability, people on low incomes, people with limited education and employment, older people, Aboriginal and Torres Strait Islanders and people in rural areas were most affected by the digital divide.

At first blush, writer and documentary maker Polly Morland’s A Fortunate Woman is the antithesis of Greene’s book. In lyrical, reflective prose, Morland charts the daily life of a female GP who works in a picturesque rural English setting. Medical technology is barely mentioned; instead the focus is squarely on the doctor–patient relationship. This relationship is precious, Morland argues, and also under threat.

Morland’s book is charged with great admiration for her doctor-subject and an anxiety that the way this doctor works may not be sustainable. Of general practitioners in Britain as a whole, she writes:

Workloads have increased. Practices and their teams have got larger. The role of technology has expanded. Part-time working has become the norm [as it] is often the only way to endure the pressures of the job. All the while, the wholesale management of risk according to standardised guidelines trumps the judgement of individual doctors… As patient numbers have risen, access to a doctor, any doctor, has become the overriding priority, and individual relationships find themselves pushed to the margins.

Morland reports “a rising sense” among GPs that these pressures constitute “nothing less than an existential emergency.” Concerns that something vital is being lost have fuelled “an intensifying research effort to understand, articulate and quantify the value of the human relationships within medical care, before it’s too late.”

What will become of the doctor at the bedside? Richard Baker

This is not a uniquely British phenomenon. Pandemic imperatives and stresses aside, many Australian GPs are struggling with the pressures of running a small business in addition to their medical work, which is intellectually demanding and time-consuming enough. Medical graduates, meanwhile, are turning their backs on general practice as a career. Recent Western Australian research shows that the number of medical graduates working as GPs more than halved among those who graduated between 1985–87 and 2004–07, dropping from about 40 per cent of graduates to about 15 per cent.

Why so? Commentators point to the negative press general practice often receives during student training and the failure of Medicare rebates to adequately reflect the cost of providing good-quality care. Yet, as Morland observes, general practice is the speciality that provides the bulk of continuity of care and disease prevention. This counts for a lot: in fact, Morland claims, there’s evidence that continuity of care is linked to lower death rates. “An existential emergency” may not be an overstatement.

Morland came to write her book soon after reading writer and critic John Berger’s A Fortunate Man, first published in 1967 and reissued by Canongate books in 2015. By all accounts this slim volume has a minor cult following in the British medical world. It takes as its subject a male GP Berger met through a mutual friend; Berger gives him the pseudonym of Dr John Sassall. Berger portrays a highly admirable GP, knowledgeable, capable and completely dedicated to his patients’ physical and psychological wellbeing. He was also mentally unwell at times. A sufferer of what was thought to be untreated bipolar depression, he suicided a year after the death of his wife.

The title of Berger’s book, then, carries a chilling irony. As Gavin Francis, a British GP and writer who contributed the introduction to the new edition, wrote in the Guardian, “A careful reading of A Fortunate Man reveals its title to be a paradox; fitting for a study of a man whose very openness to experience — his gift to the world — was also his undoing.”

Further impetus for Morland’s book came from a twofold discovery: that the bucolic valley in which A Fortunate Man was set was the same valley in which she now lived; and that the current female GP in the valley had decided on her career path after reading Berger’s book as a seventeen-year-old. A Fortunate Woman is both tribute and palimpsest. It reverentially references the text that inspired it while replacing John Sassall with his contemporary female counterpart, his style with hers.

This female GP, known throughout Morland’s book only as “the doctor,” is of a different generation, and much has changed since Sassall’s time: general practice is more regulated and bureaucratic; patient numbers have increased, as has the complexity of care; and the GP workforce in Britain is now 69 per cent female. (In Australia that figure is just over 50 per cent.) All this has implications, for both the nature of the work and how the GP responds to its demands.

Like its predecessor, A Fortunate Woman can be viewed as an extended photo essay. Berger’s book contained black-and-white photos by Jean Mohr, some showing Sassall examining and treating patients with both doctor and patients clearly identifiable. Mohr also photographed the landscape in which Sassall worked.

Richard Baker’s photos in A Fortunate Woman are in the same mould, except they were taken during the pandemic, and the doctor’s face is largely obscured by a mask, protective eyewear and visor. Patients, too, are masked, so the anonymity of all concerned is largely preserved. These images serve as a historical record of a time when some aspects of the doctor–patient relationship we took for granted — the sharing of a close physical space, the touch of a caring hand — were not always possible.

Morland’s style is beautifully measured, its tone empathic and warm. She writes perceptively and tenderly about both the doctor’s daily interactions with patients and the external environment from which she, the GP, derives much of her equilibrium. She rides her electric bike from her cottage to the clinic, then afterwards to home visits, traversing the narrow, walled roads and winding lanes of the valley, visiting breathless elderly women, stoic farmers, even a dying child. She finds solace in a quiet evening walk with her dogs. The external environment can work against the doctor, too: the winding lanes and lack of street names make home visits a navigational challenge, and a snowstorm threatens to halt proceedings on the very first day of the Covid-19 vaccination clinic.

Morland’s GP is a country doctor archetype — a wise and caring diagnostician with unbounded energy, a good sense of humour and the patience of a saint. The last of a dying breed, perhaps. The constraints of working in such a way — economic, geographic, workforce, psychological — are continuing to tighten. Can technology save the day? Will some form of AI — the “electronic brain” envisaged by Vladimir Zworykin and his contemporaries — become our standard medium of medical care? What, then, will become of the doctor at the bedside?

The stethoscope of the early nineteenth century, Greene tells us, was a new technology of the time, with its champions and detractors. Now older physicians lament the fact that their younger counterparts don’t use the stethoscope like they do, relying instead on newer modes of listening. The future of medical practice will look different from its past: this is inevitable. Both of the books under review here are concerned with this process. Morland asks that we strive to preserve the humanity of the doctor–patient relationship. Greene urges us to stay awake to the errors of the past. •

The Doctor Who Wasn’t There: Technology, History, and the Limits of Telehealth
By Jeremy A. Greene | University of Chicago Press | US$29 | 336 pages

A Fortunate Woman: A Country Doctor’s Story
By Polly Morland | Picador | $34.95 | 256 pages

The post Quo vadis, doctor? appeared first on Inside Story.

To Sims, and many others around Australia, that’s how crucial the new tax debate is. It’s no longer just about whether Labor waves through Scott Morrison’s stage three tax cuts, amends them or abandons them. There is a much wider question, with much greater consequences for our country.

Governments can never satisfy us all. But from hospitals to defence, from childcare to aged care, from schools to fixing potholes, government services are falling way short of what Australians need and expect from their country. That shortfall helped Labor get into government. Now Labor’s there, what is it going to do about it?

Labor came to office as the flagbearer of many Australians’ hopes for a government that would end the chronic underfunding of education, health and welfare, not to mention the miserly $47.74 a day we give the unemployed to live on.

Some of those areas have now reached the point where things fall apart. GPs, tired of being cast as the poor cousins to specialists, are deserting country towns and suburban practices, and young doctors are not replacing them. Aged care homes and childcare centres are perpetually short-staffed because low pay and high workloads create constant turnover. Across the board, Australia is short of skilled workers because apprentice wages are so low that only half of them stay on to complete their training.

We could all add more examples. To me the most important is that Australia now finds itself in the most dangerous environment since the second world war, yet the Coalition kept defence spending to just 2 per cent of GDP (lower than in the 1960s when we faced no real threat) and settled on submarines that will be delivered between 2038 and 2050.

Faced with all these needs, Labor nonetheless went to the election with a platform of relatively modest, tightly targeted new spending, promising no new taxes and a big tax cut primarily for those in least need.

You can understand why. It wanted to be elected, so it played safe. And in 2025 it wants to be re-elected, so it doesn’t want to risk breaking any promises now. At least, not yet.

You see what Rod Sims meant? All those spending goals require more money, much more money. In the short term, the only way governments can get more money is by raising taxes, to reallocate spending from private purposes to public ones. What do we want Australia to be?

The looming budget is the government’s first test — and the timing is not good.

The fallout from Russia’s invasion of Ukraine (amid other factors) has lifted global food prices almost 50 per cent above pre-Covid levels, blown global energy prices to several times pre-Covid levels, provided cover for businesses everywhere to sneak their prices up — and could throw some big economies into recession.

The International Monetary Fund this week estimated that after decades of low price growth, global inflation has jumped to 8.75 per cent. Even with central banks slamming the brakes on hard (which the IMF applauds), it predicts global prices will rise 6.5 per cent next year before returning to something like normal in 2024.

Contrary to some commentary, the IMF is not forecasting a global recession; its half-yearly World Economic Outlook is towards the optimistic end of the spectrum. It predicts the global economy to grow by a relatively low 2.7 per cent next year, dragged down by global supply disruptions, a permanent slowing of China’s growth rate (to 4.4 per cent) and the fallout from the war in Ukraine.

It expects the United States to keep growing, albeit slowly (1 per cent); other forecasters expect much worse. The IMF envisages some big developing economies like India (6.1 per cent) and Indonesia (5.0) more or less hurdling the upheaval, while Brazil, Russia and Turkey now seem to be doing better (or in Russia’s case, less badly) than was forecast six months ago.

If there is a recession, it would be in the advanced economies — whose growth collectively is expected to slump to 1.1 per cent — and centred in Europe. Germany, Italy and Sweden are forecast to experience mild recessions: no upsurge in unemployment, just a year without growth.

On the IMF’s forecast, Australia will also be hit. It expects our growth to fall to 1.9 per cent next year and 1.8 per cent in 2024, and to stay low thereafter. Unemployment would gradually edge back towards 5 per cent, per capita growth would total just 4 per cent over five years. Governing Australia would not be fun.

These are only forecasts. But clearly the budget outlook is far worse than the one Josh Frydenberg unveiled in his budget in March. And even that projected a string of hefty deficits as far as the eye can see. At a time of record mineral prices and low unemployment, there is no good reason why Australia should have run up new debt of $32 billion in 2021–22.

A cardinal rule of budgeting is that, by and large, you pay for what you spend. If you don’t, you are leaving the bill for the new generation to pay. There are exceptions: you run deficits in bad times and cover them by running surpluses in good times. Infrastructure spending largely benefits the next generation, so it is fair to borrow to build. But at federal and state level — especially in Victoria and the ACT — governments have simply lacked the courage to make us pay for what they spend.

This combination of a grim global outlook, a grim state of the budget and a government still new to the job does make it likely Labor’s first budget will be, as treasurer Jim Chalmers keeps saying, responsible.

I assume he means that Labor will give priority to reducing the budget deficit. And that in working out the numbers, Treasury will err on the side of caution in guessing future energy prices, and hence company tax revenue. And that any new taxes and spending will implement the commitments Labor made in the campaign, and little else. And, of course, that Labor will go after the Coalition programs it has identified as rorts.

All that buys time. But circumstances are conspiring to force Labor to confront Rod Sims’s question: what does it want Australia to be? To deliver First World services, you need a First World revenue base. And for Australia, that means higher taxes.

Let’s take the long-term issue first. Australia is a low-tax country. At the government’s recent jobs summit, economist Ross Garnaut cited OECD figures showing that total federal, state and local government tax revenue as a share of GDP was 5.7 percentage points lower than the developed country average. That’s a shortfall of almost $140 billion a year.

The IMF’s data for total revenue reports a similar gap: governments in Australia raise 5 percentage points of GDP less revenue than the median advanced economy. In 2019 federal, state and local governments raised 34.6 per cent of GDP, well below 40.7 per cent in Canada (the country we most resemble), 46.5 per cent in Germany, and an average of 50.6 per cent in Scandinavia.

In part, that’s because retirement income in Australia is semi-privatised through superannuation, whereas retirees in almost all other Western countries, even the United States, rely on government-run retirement benefits funded by a separate social security tax on income. (The reason Australia appears to rely so much on income tax is that we have only one income tax. Most other Western countries have two, under separate names.)

But the OECD’s data show Australia also has the highest private spending on education of any OECD country, and the third-highest “voluntary” private spending on healthcare. Unemployment benefits are among the very lowest in the Western world.

Once, Labor ministers might have rebelled against this two-stream system in which the best services are reserved for those who can pay the fees demanded in the private sector. Now, as we saw when the Gillard government squibbed on the Gonski report’s school funding reforms, preference to private schools is one British tradition Labor still loyally supports.

In theory, Labor could use more desirable ways to meet the cost of bringing Australia’s services to the standards we expect. It could reduce spending on lesser priorities and reallocate the savings. Or it could take on the politically difficult economic reforms needed to speed up Australia’s sluggish rate of productivity growth.

In reality, speakers at the revenue summit agreed, the gap between today’s service levels and those we expect in aged care, the health system and so on is too vast to be filled by cutting services in other areas. Sims called it “self-evident” that savings from those cuts, while they could and should be made, are not on the scale needed to get us where we want to be.

For ten years until recently, Sims chaired the Australian Competition and Consumer Commission. The experience has made him sceptical of the potential for dramatically improving our productivity and hence growing a bigger economy. Rapid productivity growth, he said, requires increased competition — and the reality is that business is reducing competition, not increasing it.

“Our political debate always favours low taxation,” he said. “We have to point out that what comes with that is low expenditure. And we have to keep asking the question: is that what we want? If you want to spend extra money, you have to raise extra revenue. There’s just no avoiding that.”

He went on: “If you are against higher taxation, then you are against higher government expenditure… Many do not realise that in opposing taxation they are opposing extra spending on health, education and much else. I think we need higher taxation. I think it’s unavoidable.”

Why? Sims and other speakers at the summit gave several reasons:

1. Australians need better services

Annie Butler of the Nurses Federation cited the findings of the aged care royal commission: neglect and substandard care are widespread and systemic in aged care because the industry is underfunded by $10 billion a year. “Ridiculously low” wages lead to high staff turnover and hence shortages.

ACTU secretary Sally McManus argued that a lot of the crises Australia is experiencing in health and other services result from years of “chronic underfunding.” Economists predict that 30 per cent of all jobs created in the next decade will be in caring for others, but unless those jobs are better paid, workers will not stay in them. Our priorities have to change.

2. The transition to a low-carbon economy

The big economic reform facing Labor is going to be an expensive one: valuable in the long term but costly upfront. Business and government will need to invest tens of billions of dollars in building the solar and wind farms that will generate the power, the batteries that will store that power, and the transmission lines that will bring it from the inland to the cities. And if our coal stations are to close down by 2035, this money needs to be spent in the next decade or so to guarantee that we will still be able to turn on the lights.

The task is made even bigger and more crucial by the need to transition cars from oil to electricity and households and businesses from gas to electricity. Tim Washington, chair of the Electric Vehicle Council, told the summit that electric vehicles comprise, at best, 3 per cent of Australian car sales, compared with 15 per cent in other Western countries. With a global shortage of EVs likely to persist, he urged business and government to manufacture them here, using Australian designs, software, metals and lithium to create an entire value chain. He’s not likely to get that.

Fortunately, there is an ideal solution. Unfortunately, only the Greens, teal independents and economists support it. It is a carbon tax.

Sims confessed he found it baffling that so many Australians want action on climate change but instantly condemn the idea of a tax on carbon. Governments are going deeper into deficit to subsidise solar panels and electric vehicles, whereas the carbon tax would give the whole economy an incentive to decarbonise while raising taxes to fund the investments required.

“No such transition can be painless,” he said. “We need to decide whether we are serious about climate change. If we are, then it can be funded by a tax that will have the benefit of directly changing behaviour while insulating low income earners [through compensation].”

3. Get out of deficit and start paying down debt

Australia has less government debt than most Western countries, but only because the Hawke, Keating and Howard governments made fiscal responsibility a priority from 1985 until 2005. In both 2009 and 2021, as a resilient Australia emerged from the global financial crisis and Covid lockdowns respectively, our governments kept piling on stimulus as if money were no object. And the pollies’ fear of tax rises — much of it due to the vicious hostility of the Murdoch press towards anyone, especially anyone from Labor, brave enough to impose them — has kept us in deficit ever since.

Federal government revenue in this century peaked at 25.6 per cent in 2005–06, when it was 24.1 per cent of GDP. Since then spending has swollen to 26.8 per cent of GDP. Yet, far from keeping pace, revenue has fallen — because governments are frightened of raising taxes.

As ANU economist Ben Phillips put it, “We have plans for increased expenditure, but not for increased revenue. All we’ve got to increase revenue is bracket creep: it’s sneaky, but it works.”

(Bracket creep is the additional tax you pay when inflation pushes more of your nominal income into a higher tax bracket. The stage 3 tax cuts are often defended as simply handing back that extra tax. But only the high income earners will get their bracket creep back, and they get back more than they lost.)

Phillips estimates that Australia faces a revenue gap of $25 billion to $50 billion a year for the next decade. The summit heard lots of suggestions on how to close that gap: one that Labor has flagged for this budget, and others that we should be debating and putting to a new tax review.

Sims alone proposed five:

• Crack down on multinationals avoiding tax by non-commercial transfer pricing, including paying ridiculously high interest rates or “marketing fees” to a head office in a tax haven.

• Ensure Australians benefit when our mineral and energy resources are extracted. Norway takes almost 80 per cent of the revenue from its oil and gas fields, yet Australia allows companies to take those resources for virtually nothing. The petroleum resource rent tax, which is meant to do the job, desperately needs big repairs — and an extension to cover coal and iron ore.

• Introduce an excess profits tax, as the European Union has done recently. Australian Bureau of Statistics figures show that in the Coalition’s nine years in office, mining output rose by $195 billion but wages in the industry by just $5 billion. Net profits by the mining industry grew by $190 billion, yet taxes on mining shrank by $0.1 billion. If there is ever a time for a tax on excess profits, it is in Australia now.

• A carbon tax. (See above.)

• At state level: a comprehensive land tax covering all private property except farmland, to replace stamp duty on conveyancing. Economists generally see land tax as a most efficient tax. Sims called it a progressive tax, “based on assets that cannot be moved,” that produces a steady revenue flow.

• Road-user charges will be inevitable as electric vehicles replace petrol-driven cars. Their advantage is that they can be fine-tuned for vehicle type (trucks pay for the damage they do to roads) and time of day (peak-hour pricing).

Other speakers added at least another five:

• Prune tax breaks for superannuation.

• Prune or phase out negative gearing of property investments.

• Scrap fossil fuel subsidies, including the mining industry’s exemption from fuel excise.

• End concessional tax rates for family trusts.

• Increase the Medicare levy to pay for extra spending on aged care.

Sims emphasised that the reforms would need to be sold as a package, with compensation where appropriate, as the Hawke government did when it reformed tax in 1985. That package was preceded by a tax review by Treasury and a tax summit where a wide range of groups put their case.

Albanese has pledged no new taxes in this term apart from the ones Labor took to the election (primarily a crackdown on tax avoidance by multinationals — no votes lost by tackling that). But independent MPs Allegra Spender (Wentworth, NSW) and Zoe Daniel (Goldstein, Victoria) both urged a new tax review “with everything on the table” — with Spender adding “including the GST” and a hopeful plea: “We need to have grown-up conversations about tax.”

Well, good luck with that. I suspect most tax economists would agree that the GST rate should be raised, or its field widened, or both. New Zealand lifted its GST rate to 15 per cent back in 2010 without suffering any visible social collapse, and its GST is far more comprehensive than ours. That’s the main reason its government can spend more than ours.

The left needs to stop demonising the GST and think of tax reform as a package. You can introduce or increase or widen a GST fairly so long as you design the right package — as we saw in 1999 after the Australian Democrats stopped the Liberals using the GST to shift more of the tax burden onto lower and middle income earners.

But so long as we are unable to see any bipartisanship on tax, the GST will remain a no-go area. And bipartisanship is probably off the agenda as long as Peter Dutton is Liberal leader.

Where does that leave the stage 3 tax cuts? It looks like this movie has ended now, with treasurer Jim Chalmers apparently losing the fight despite his skilful attempts to persuade colleagues to revise, reduce or even scrap the cuts — which would be in line with his theme of protecting the budget in increasingly dangerous times and giving support only to those who really need it.

But good movies these days have a sequel, and these tax cuts won’t take effect until mid 2024. Given his impressive debut in the role, Chalmers has time to perfect it when he plans his next budget. He knows the case for either abolishing the cuts or reducing and retargeting them is very strong.

Stage 3 contains three elements:

• abolish the 37 per cent marginal tax rate on income earned between $120,000 and $180,000

• raise the threshold for the 45 per cent top rate from $180,000 to $200,000

• reduce the standard 32.5 per cent rate to 30 per cent — which would then be a flat tax rate for all income from $45,000 to $200,000.

Modelling by the Parliamentary Budget Office and by Ben Phillips found the first and the third are the expensive items. And the consensus at the summit seemed to be that if there is compromise, we should keep the third while scrapping the first.

A few points are important to note.

First, these tax cuts were proposed by treasurer Scott Morrison way back in 2018, six years before they would take effect. Since then, we have had a global Covid pandemic and the global inflation breakout. Committing to tax cuts six years before they took effect had no economic rationale. What drove it was politics. Morrison assumed the budget in 2024 could afford it. He was wrong.

Second, the cuts follow stage 1 (in 2018), directed to lower-middle income earners, and stage 2 (in 2020), focused on upper-middle incomes. Stage 1 was small, and has since been abolished by the Coalition itself. Stage 2 was bigger: it cut taxes for people earning less than $90,000 by $10 a year, and taxes for people earning over $120,000 by $1890 a year. The idea that high earners have been kept waiting while others have had tax cuts is quite untrue.

Stage 3 is seriously big money. The Parliamentary Budget Office last year estimated their cost at $18 billion in year one (2024–25), then more than doubling to $37 billion by year nine (2032–33). Treasury is now revisiting those numbers — and the cost will almost certainly be even higher now.

But even on the PBO’s 2021 estimate, that would reduce total government revenue by 3.5 per cent initially, and by more than 4 per cent by the start of the 2030s. That is a huge cut in revenue at a time when the budget is unable to cope with Australia’s existing spending needs, let alone the new ones coming over the horizon from the ageing of our population, China’s attempt to assert hegemony over the region, the excesses of the NDIS, and so on. We need tax rises, not tax cuts.

Third, the PBO estimates that 78 per cent of those billions of dollars would go to the richest 20 per cent of Australians. That’s largely because they pay 68 per cent of all income tax — but that in turn is because they get such a high share of the nation’s income. They would rank low on a list of those in need.

That said, it seems fair to say that the threshold of $180,000 for Australia’s top tax is too low. If Chalmers and his colleagues want to compromise, one option they might consider is to reduce the 37 per cent rate to 35 per cent with the same thresholds as now — but add a new 40 per cent rate for income from $180,000 to $200,000, and a timetable to raise that threshold to $250,000. Over time, that would save the budget a lot of money, without taking everything from those who would gain from the plan Labor promised them. •

The post Time to talk about tax appeared first on Inside Story.

As of 9 September, only 2 per cent of the population of low-income countries had received at least one vaccine dose. In lower-middle-income countries the figure was 30 per cent, in upper-middle-income countries a slightly more respectable 54 per cent, and among high-income countries 65 per cent. Not one low-income country had met the World Health Organization’s target of vaccinating at least 10 per cent of their people.

The averages hide more shocking disparities. While more than 80 per cent of Australians, Portuguese and South Koreans are fully vaccinated, many governments are struggling to get first doses to even half of their population. In the poorest nations — countries like Haiti, Yemen, Sudan and the Democratic Republic of Congo — less than 1 per cent of the population have had even one dose.

Despite these obvious shortfalls, the British healthcare research company Airfinity calculated in September that rich countries had surplus supplies of more than 500 million shots, even taking account of their planned booster programs, and that the figure is likely to rise to 1.2 billion by the end of the year.

An analysis by the Financial Times shows that rich countries have given out more booster shots in the last three months than poor countries have administered in total doses all year. If those surplus vaccines aren’t sent to the countries most in need, as many as 2.8 million lives could be lost this year.

Epidemiologists are concerned that the current vaccination pattern will prolong the pandemic and create an opening for more dangerous and transmissible variants. The OECD sees inequalities within and between countries escalating, recovery of the global economy slowing, and international travel and tourism continuing to be affected.

An International Chamber of Commerce study found that the global economy stands to lose as much as US$9.2 trillion if governments fail to ensure low-income countries have access to vaccines. Up to half that impact would fall on advanced economies themselves. Even the US intelligence agencies are worried: their latest annual threat assessment concludes that the financial and humanitarian crises experienced by some hard-hit developing countries will increase the risk of internal conflict, government collapses and migration.

How did we get to this point? The course of the pandemic provides part of the answer. It initially fell hardest on high-income countries, which very quickly made early purchase bids for vaccines at prices largely governed by the market. Some countries (the United States, Britain, Canada and eventually Australia) purchased enough vaccines to cover their populations several times over. The G7 countries as a whole, home to just 13 per cent of the world’s population, have purchased more than a third of the world’s vaccine supply — including almost all the current mRNA production from Moderna and Pfizer/BioNTech.

In response to the demand, vaccine manufacturers set their official prices in a variety of ways. Larger, established companies like Janssen (the vaccine manufacturing arm of Johnson & Johnson) and AstraZeneca pledged to market vaccines at no profit during the pandemic. Pfizer’s CEO said the company planned to price for a marginal profit. Novavax plans to make an appropriate return. Newcomer Moderna priced to generate a profit.

In reality, vaccine prices are a movable feast, deeply dependent on quantity, negotiating capacity and demand. UNICEF, the UN children’s fund, has found that many middle-income countries are paying as much as high-income countries, if not more. Researchers at Oxfam calculated that Pfizer/BioNTech and Moderna received US$100 billion of taxpayers’ money to fund research, development and early purchases of their vaccines, but are charging up to twenty-four times the cost of production, and rising.

The AstraZeneca jab is seen as the cheapest of the main Covid-19 vaccines. That might be true in Europe, where the company’s contract with the European Union specifies just US$2.15 a dose, but not elsewhere: the British Medical Journal reported earlier this year that South Africa had paid AstraZeneca US$5.25 per dose for 1.5 million doses to be administered to healthcare workers.

We might all agree that being vaccinated during a pandemic is a humanitarian entitlement, but international action so far has been driven just as much by a concern among Western powers that Russia and China have more successfully pursued vaccine diplomacy with vulnerable nations.

China boldly declared its Sinovac and Sinopharm vaccines to be a “global public good”— as opposed to a commercial product — and has supplied them to some sixty countries, in many cases at no cost. This effort seems intended, at least partly, to undercut purchases already made from Western suppliers but not yet delivered.

But now, with the Chinese vaccines displaying lower efficacy, many of the countries that have used them face a public health dilemma.

COVAX, a global hub for buying and distributing vaccines created by the World Health Organization, the Coalition for Epidemic Preparedness, UNICEF and Gavi, is designed to help countries that would otherwise struggle to negotiate affordable vaccine purchases. It uses funding from governments and donors such as the Gates Foundation to make its own contracts with vaccine manufacturers and deliver supplies where they are needed.

Despite the grand vision, COVAX is 500 million doses short of its vaccine distribution goals. Its aim was to distribute at least two billion doses, two-thirds of them to lower-income nations, by the end of 2021. But only 16 per cent of contracted doses have been delivered, and the two billion doses target has been pushed out a year.

COVAX has struggled for several reasons. Prime among these is the “vaccine nationalism” of high-income nations, which have been slow to meet their commitments to the hub. Though billions of doses have been promised, actual contributions have been paltry, and too often they are small donations of soon-to-expire doses made at the last minute.

Australia is a case in point. The federal government promised A$130 million to COVAX, of which only A$44 million has so far been provided. It promised forty million vaccine doses from the national stockpile and a further twenty million doses for countries in Southeast Asia and the Pacific by the end of 2022. To date, fewer than five million doses have been supplied to developing nations.

In fact, Australia seems to be taking as much as it is giving. The Nine newspapers have revealed that the federal government has bought at least 500,000 Pfizer doses from COVAX to boost local supplies, and the government’s own figures show that it has a A$123 million option to purchase a total of twenty-five million doses for Australian use.

COVAX had hoped that the Serum Institute of India, the world’s biggest vaccine manufacturer, would boost its stockpile, but when Delta infections grew in March this year the Indian government limited exports in order to supply the domestic market.

Around eleven billion doses are needed to fully vaccinate 70 per cent of the world’s population. More than six billion doses will have been administered by the end of this year, leaving a deficit of about five billion doses. A majority of people in the lowest-income countries will wait another two years before they are fully vaccinated.

The problems with COVAX have led policymakers to consider other approaches. Longstanding calls to increase vaccine manufacturing within less well-off countries — extending back to well before the pandemic — have grown louder, with a variety of approaches under discussion. Global health advocates argue that vaccine production must spread beyond the current concentration in the United States, Europe, India and China, not just to tackle this pandemic but also to be ready for future viruses.

A group of countries led by South Africa and India called last year for the World Trade Organization to issue a waiver of intellectual property protections for Covid vaccines. More than one hundred Nobel laureates and seventy-five former heads of state added their support in April, calling on US president Joe Biden to suspend vaccine patents in order to “expand global manufacturing capacity unhindered by industry monopolies that are driving the dire supply shortages blocking vaccine access.”

Despite Biden’s support, the proposal has encountered fiery opposition from the pharmaceutical industry. Vaccine companies say they are already expanding production and the move would have little if any practical effect. Even if they had the formulas, few countries have the trained personnel needed to produce Covid-19 vaccines, and supplies are already stretched.

The World Health Organization has asked innovating firms to contribute their intellectual property to the UN’s Medicines Patent Pool, and proposes a role for itself to coordinate technology transfers, facilitate training, help countries organise the necessary investments in factories, and assist with regulatory approvals and agreements on royalties.

In April the African Union’s Centres for Disease Control and Prevention announced an ambitious plan to establish new vaccine factories with the aim of reducing the continent’s reliance on vaccine imports in general. A push is also being made for an mRNA vaccine manufacturing hub in South Africa. Moderna has indicated it is opposed to patent waivers; now it seems that South African researchers, with WHO support, will attempt to create their own mRNA vaccine using reverse-engineering techniques.

In a recent article in the New York Times, experts in vaccine development and production say that manufacturing mRNA vaccines in developing countries is feasible. Despite resource and timing issues, this approach would give countries the capacity to vaccinate against not just Covid-19 but a whole range of other infectious diseases endemic to low-income countries.

American economist Alex Tabarrok is among those who have argued that patents are not the major obstacle to the current vaccine supply problems. A patent waiver might be largely cost-free for rich countries, he says, but would do little to relieve supply shortages or make distribution fairer. “Sorry, there is no quick and cheap solution,” he writes. “We must spend… Bottom line is that producing more takes real resources not waving magic patent wands.”

Regardless of the force of that argument, two examples highlight why local manufacturing will be vital in the medium to long term. First, the cost of the WHO-recommended vaccine program for children under two years of age — which was set before the pandemic and currently includes eleven vaccines — has been skyrocketing. By 2020 the cost was estimated at between US$37 and US$101 per fully vaccinated child. These important childhood vaccination programs could become unaffordable, especially with the economic fallout of the pandemic.

Second, important newer vaccines — the vaccine against the human papillomavirus, the causative agent of cervical cancer, for example — are already out of reach for many low-income countries. Every year, more than 300,000 women die from cervical cancer, mainly in low- and middle-income countries; nearly all those deaths are preventable by vaccination.

Although the pharmaceutical industry is frequently — and often justifiably — portrayed as purely profit-oriented, the major companies have made efforts over the past decade to support “open source” models of production. These schemes have generally focused on the neglected tropical diseases that receive little research and development funding despite affecting a significant proportion of the world’s population. Could more be done to encourage this approach?

That such hopes are not overly optimistic is indicated by last week’s announcement that US-based pharmaceutical giant Merck has reached an agreement with the UN Medicines Patent Pool to license the international manufacture of its potentially lifesaving antiviral drug molnupiravir for treatment of Covid-19 in adults. This move is expected to create broad access for its use in more than one hundred low- and middle-income countries.

According to the announcement, the three patent holders, Merck, Ridgeback Biotherapeutics and Emory University, “will not receive royalties for sales of molnupiravir under this agreement for as long as Covid-19 remains classified as a Public Health Emergency of International Concern by the World Health Organization.” Many will be watching for signs of other companies following Merck’s lead.

Back in Australia, meanwhile, the End Covid For All campaign last month released a report urging the federal government to lift its commitment to the global vaccination effort by A$250 million in funding and twenty million extra vaccine doses. The group’s Tim Costello urged Australia to “become a vaccine factory for the region.” Help is needed with testing, supplies, transportation and vaccination efforts to ensure these donations deliver benefits effectively and efficiently.

Covid-19 vaccines are a precious resource. Australia needs a plan to ensure it plays its role internationally in making sure vaccinations are managed fairly, without unnecessary price spikes, hoarding or wastage, in recognition that no country is safe until every country is safe. •

The post Bridging the jab divide appeared first on Inside Story.

I’m not sure how many people in Perth picked up the clue in that refrain, but those who did would have known that something distinctively Dutch was brewing. That phrase is the call sign of Buurtzorg (spoiler: in Dutch buurt means neighbourhood and zorg means care), a nurse-led organisation that has revolutionised home care in the Netherlands.

Buurtzorg intrigues policymakers around the world looking for better ways to enable elderly people (and others with care needs) to live independently with less formal care. What’s not to like about a model that KPMG found “halves costs, improves quality and makes happier caregivers,” as Forbes magazine enthused?

Admirers of the Buurtzorg model are not confined to healthcare, either. La philosophie Buurtzorg, as the French call it, has become something of a standard-bearer for a nascent movement rallying to put human values back at the core of government.

Neighbourhood Care — which is indeed Buurtzorg’s partner in Australia — launched under the radar, in difficult times. At first glance, it appears to be just another service provider competing for dollars under the National Disability Insurance Scheme. And, who knows, that may yet prove to be so. There’s plenty of noise in that crowded space, and good reason to suspect the fine intentions of new entrants. “A lot of people come into the sector with lovely values and mission statements, but they are there for an opportunity, to commodify care,” says Wollongong University health services researcher Anita Westera, who points to the rapid growth of digital care platforms like Mable and Kynd as the logical extension of transforming aged care and disability into a marketplace predicated on consumer choice.

Chief executive Arnold Stroobach tells me Neighbourhood Care employs twenty-six people. It has three teams operating in Western Australia — two in metropolitan Perth and another in Northam, an hour east of Perth — and a small presence in Ipswich, in Queensland. These self-managed teams are the central unit of the Buurtzorg model; in the Netherlands, where it is the biggest community care provider, Buurtzorg’s decentralised network has 1000 of them.

A Buurtzorg team consists of ten to twelve trained nurses. Once a team grows bigger than twelve, it splits into two (an idea pinched from an unconventional Dutch tech entrepreneur, the late Eckart Wintzen). Each nursing team works in a buurt of up to 10,000 inhabitants and typically divides the care of fifty to sixty frail elderly people between its members. Referrals come from hospitals, doctors or families.

The nurses organise everything themselves, taking charge of the complete process of caring for their patients and running their own small enterprise. They are connected to each other and the other teams in the decentralised network by an internet-based platform called Buurtzorgweb. There’s no middle management to refer problems up to. If a team has internal conflict, Buurtzorg offers the assistance of “coaches” — there’s one per forty teams — who are trained in team dynamics. If a team can’t solve its problems, it closes.

Neighbourhood Care bears only a sketchy resemblance to this model at the moment. Apart from working in disability rather than aged care, only one team is operating at full capacity, the one in Northam, and its employees are not nurses but therapists and trained support workers. The challenge for the organisation is to comply with the requirement of the NDIS — where every client has a plan with prescribed goals and line items — while trusting the operation to the team.

“You can’t copy and paste the Dutch model,” says Stroobach. “You have to find a way to adapt to local conditions.” The team dynamic is different in a non-medical sector, he says, but they haven’t changed the principles of Buurtzorg a lot. And they’ve just passed their first NDIS audit. The next step is to register for the federal government’s My Aged Care scheme.

Australia’s sprawling suburbs and isolated regional towns are a very different kind of buurt from those in the Netherlands’ densely populated lowlands. But Buurtzorg’s big idea is small teams not small areas, Stroobach says. “It’s human-scaled.” It has been a slow business finding the right people for the teams, frontline workers who know what’s expected of them and can wear the responsibility of self-management. The Dutch love it, but it’s not a familiar concept in Australia, where our default position is the traditional hierarchy.

Stroobach finds the analogy with a sporting team works well though. “In sport, feedback can be brutal, but it’s acceptable. In the workplace here it’s almost a miracle to have feedback.” And some clients aren’t comfortable with the Buurtzorg model — they don’t believe the support worker can make his or her own decisions. It’s a tricky dynamic, he says, and “you can kill it off if you’re not careful.”

When I speak with Buurtzorg’s founder, nurse turned social entrepreneur Jos de Blok, he seems happy enough with what’s happening in Australia so far. “In my opinion, they are doing very well,” he says. It’s quite an effort in the first few years, he adds. The thing is to break even: “If it is stable, you can easily grow.” He thinks it will take five years for Buurtzorg to “get somewhere” in Australia.

That’s an interesting time frame, given the speed and magnitude of Buurtzorg’s growth in the Netherlands. From a standing start in the winter of 2006, Buurtzorg attracted enormous interest, both from nurses who deserted its competitors to join Buurtzorg teams, and from the ministry of health, which actively promoted the development of the model.

Within a decade, Buurtzorg was employing more than half the country’s community nurses, and the government had adjusted the payment system to make room for its flat-rate billing. By 2015, two independent audits (by KPMG and EY) had assessed the model’s impact on some of the most chronic problems facing Dutch healthcare — dissatisfied patients, overstretched and disillusioned staff, and a constant pressure on budgets. Those reports were immensely helpful, de Blok says. “When you are able to show that our model is 40 per cent cheaper for society, you get political acceleration.”

Buurtzorg employs more than 14,000 people in the Netherlands. It is mostly engaged in nursing frail elderly people in their homes, but it also has teams working in mental health, family and child services, and domestic help, and there is discussion in the Netherlands and elsewhere about whether and how the Buurtzorg principles can be applied to education, policing and other social services. De Blok doesn’t argue with that. “For me, it is not really a business model, it is a way to look at society,” he says.

De Blok is driving while we talk, heading to The Hague for a meeting with the Dutch health minister. It’s a Monday morning, but traffic is light. He’ll be on time, which is a good thing because Hugo de Jonge is “not particularly a friend,” he says. Previous ministers of health have been helpful, but de Jonge has been critical of Buurtzorg. Plus, he has a “top-down way of doing things.” You can see where this is going. Top-down would press all de Blok’s buttons.

But he’s not necessarily meeting his minister as a supplicant. The Buurtzorg model is one of the Netherlands’ more famous exports these days — perhaps not up there with edam or windmill biscuits, but active in twenty-five countries. Moreover, a lot of Buurtzorg’s competitors have adopted its model. De Blok estimates up to 70 per cent of healthcare organisations in the Netherlands have switched to self-managed teams. “My ambition in Holland was to change the healthcare system,” he says. “We succeeded quite well.”

Reducing complexity: Buurtzorg’s founder, Jos de Blok. Linelle Deunk/Lumen

He has no need to blow his own trumpet when so many others are ready to do it for him. Frederic Laloux devoted a section of his influential management book Reinventing Organizations to Buurtzorg’s model; the Royal Society of Arts awarded de Blok its Albert Medal in 2014 (other recipients have included Francis Crick and Tim Berners-Lee). The young Dutch historian who famously disrupted the 2019 Davos meeting, Rutger Bregman, is a fan. The list goes on. De Blok and his organisation are a global phenomenon.

The minister would know that. He would also know that everything has its season. Has Buurtzorg already fulfilled the potential that Dutch management professor Sharda Nandram suggested it had “to permanently change the landscape of the healthcare sector” or is it only just hitting its stride? It’s hard to know. There are still a lot of blanks in the picture.

Buurtzorg is de Blok’s brainchild and he is a gifted communicator, in an understated Dutch way. If you watch him giving a TED talk, it isn’t difficult to appreciate why his ideas have such a wide reach, not just in Europe but in places where Dutch ideas have historically had little purchase, like China, India and Japan.

He makes eliminating overpaid managers, luxurious offices and layers of bureaucracy — and giving teams of nurses the authority and responsibility for providing care to housebound older people with chronic disease and disabilities — sound incredibly obvious.

De Blok is no innocent. It’s not that he doesn’t see the problems that healthcare systems all over the world have — who doesn’t? — but rather that he makes a virtue of reducing complexity.

“What I see in a lot of countries is that systems are increasingly complicated and frustrations are becoming worse and worse,” he told University of Cambridge business professor Jaideep Prabhu, whose new book about government tells the Buurtzorg story in detail. “I want to show that it’s easy to change.”

But that’s the question, isn’t it? How easy?

It’s worth spending a little time looking more closely at how Buurtzorg developed in the Netherlands before exploring why full take-up of the model has not quite happened yet — even in Britain, where enthusiasm for Buurtzorg is high, as former Buurtzorg staffer Paul Jansen wrote recently, but many promising teams have been absorbed back into their organisations. Jansen was chief operating officer at Buurtzorg Britain and Ireland between 2018 and 2020.

Much of the intense international curiosity and speculation about Buurtzorg centres on the question of its adaptability. Can its successes be replicated in countries with similar healthcare problems, or is it something that only the Dutch, with their famous openness to new ideas (like reinstating old water courses to avert extreme flooding, and demanding farmers cull their cow herds to reduce ammonia pollution), can pull off?

So, a short detour is needed to put Buurtzorg’s origins into context. In the early 1990s, in response to rising costs and an ageing population, Dutch politicians threw away the old public service playbook and put their faith in the three Ms of markets, managers and metrics. Even if you’re not a student of government — who would know this trend as New Public Management — you’ll recognise the ideological shift. It changed the way public services throughout the world were delivered, and nowhere more so than in Australia, where NPM retains an iron grip across government.

De Blok was working in a village with a few colleagues as a community nurse when the political winds changed. He told the journal People and Strategy that being a community nurse under the traditional, pre-NPM model of healthcare gave him everything he wanted. “I had the freedom to decide how to take care of patients. I had very good colleagues. There was no management structure, we didn’t have strategic plans, and we didn’t have planning tools. We just did what was needed. It was effective.”

And then came a directive from the top that small district nursing teams should be merged to form larger organisations run by professional managers. This would bring economies of scale, with competition driving down costs and driving up the quality of care.

That was the theory. What actually happened was that the focus of healthcare moved from caring for patients to delivering products — products like nursing, nursing extra, personal care, personal care special, guidance, guidance extra, and so on. As products proliferated, more managers were hired to control the process.

Nurses, on the other hand, were authorised only to deliver certain products in an agreed time frame and lost the personal bond they’d had with patients. Sometimes up to thirty different healthcare professionals visited an elderly person at home in a month to administer different tasks or interventions, yet there was no oversight of an individual’s health and wellbeing.

(Melbourne public health researcher Sarah Russell has made similar observations about My Aged Care, where the most common complaint about providers is the high turnover of unqualified, inexperienced and untrained support workers, strangers being sent to the homes of older people who have to “just trust they will be treated with respect and kindness.”)

Care organisations became like factories, systems replaced relationships, and the perception of what was good care and what were good solutions changed — but to what end? Patients were confused and unhappy. Nurse sick leave rates soared. And, instead of driving down costs and improving the quality of care, the reforms had the opposite effect.

De Blok spent a decade trying to work within the new system. He retrained as a manager, did a master’s degree in innovation and eventually became a managing director. But by 2004 he understood that if he wanted to recover what had been lost — the sacrosanct relationship between patient and nurse — he’d have to start his own organisation, designed and run by nurses. It would deliver only one service, which was helping people in the quality of their daily life.

The idea, de Blok has said, was to “have people around these problems who feel connected to them and can make the choices they think are the best choices… The support systems should be logical and simplified but you should not underestimate the complexity of what’s going on.”

To understand that complexity better, listen to him talking to Richard Atherton on the Being Human podcast about the kinds of decisions nurses make when they’re caring for patients in the last phase of their life. “In our society, we try to make everything explicit, we try to put it into protocol and regulations and so on, but most of the work of nurses is in the heads of people, based on years of doing things and understanding patterns. You need the environment, you need the autonomy, and the space to do these things based on your practical wisdom and intuition.”

Feeling connected: a Buurtzorg team meeting in the German city of Münster. Buurtzorg Germany

De Blok spent eighteen months designing Buurtzorg with his wife Gonnie Kronenberg and other nursing friends. He had figured out most of it, but it wasn’t until he got talking to a former colleague and IT expert, Ard Leferink, that the model came together. Leferink showed him how to scale up his idea. He would design an internet-based platform (which became Buurtzorgweb) that could be built quickly and cheaply to support nurses in their work, freeing up their time to focus on care.

Nursing teams manage their frontline workload on their iPads (the platform also allows Buurtzorg to monitor how each team is doing), and other administration is picked up by the back office operation run by Kronenberg. It’s lean: forty-five people deal with contracts, billing hours to health insurers, and supporting nurses when they have difficult cases. Overheads are low, at 8 per cent. In Australia, administration fees in the home care system average almost a third of package costs.

In its first full year of operation, 2007, Buurtzorg began with one team of ten nurses in Almelo and ended the year with twelve teams in different places and a turnover of €1 million. De Blok wasn’t surprised. He knew that if it worked then everyone would want it. It was good for nurses, good for patients, and — as would be proven within a few years — good for the system. But they did get lucky.

In the summer of 2007, the then minister of health, who’d seen de Blok on television, asked if she could join a team of Buurtzorg nurses on her bicycle. She liked what she saw and invited Buurtzorg to visit the ministry of health, and from there came an initiative that led to Buurtzorg being asked to develop a national policy based on its model. “She was wanting to find ways to change [the system] herself,” he remembers. “So she said, ‘Let’s do this together.’” Not everyone was convinced, though. There was some pushback from other care organisations and from insurers, which withheld funds, but eventually they came on board.

That’s the conundrum: people around the world like what they see in Buurtzorg, and want what it offers, but on their terms. People in top government roles can have big issues with trust and relinquishing control. “There is a lack of trust in devolving power and funding to communities that know their people best,” says Travers McLeod, chief executive of the Centre for Policy Development in Melbourne, which has invested a lot of thought and energy on the ground in community-led programs.

Trust-based organisations like Buurtzorg are difficult beasts to understand if your view is that people are fundamentally selfish. That was the starting point of NPM — that people need tangible incentives to serve the public good, which means their performance has to be measured so managers know who deserves punishment or reward. And people who ask for help must be assessed to see if they really need help, or are just trying to grab more than their share.

We’ve all grown used to thinking this way, so it’s hard work persuading policymakers that other motivations can bring out the best in people.

“Working within a system that is not open to these kinds of things is one of the most difficult parts,” de Blok tells me. “I’ve been talking for ten years with the NHS [Britain’s National Health Service]. It is so complicated in that system to create space and an environment where you can experiment and show an impact. It fits completely with the NHS first principles, and the nurses understand it, but the system is so complicated.”

Even the Danes, whose culture is highly compatible with the Dutch, are struggling to keep their first concrete experiment with two Buurtzorg-style home care teams on track. The social enterprise running the pilot filed for bankruptcy on 31 August, a week before a midterm evaluation was published by VIVE, the Danish Center for Social Science Research. The project’s director put the financial failure down to the hybrid nature of the project — citizens loved it, he said, and growth was steady at 15 per cent a month, but “systems could not keep up and we got too much resistance.” The VIVE review was ambivalent. “Buurtzorg challenges the Danish way of organising elderly care,” it reported, “and therefore there are also divided opinions about the model’s relevance and applicability in a Danish context.”

De Blok tells me he was in Denmark the previous week, and that “they want to adopt all the ideas of Buurtzorg.” He would be there again the following week for more conferences. And this is how it seems to go. A lot of conferences but remarkably little evidence yet for how the idea plays out in practice anywhere but in the Netherlands.

That said, there are sizeable Buurtzorg organisations in France, Sweden and Germany, and the European Union has invested €8 million in Transforming Integrated Care in the Community, a four-year research project guided by the principles of Buurtzorg. There are also several Buurtzorg partners in Asia, including in China, India, South Korea and Japan.

Buurtzorg Asia took some time to bed down, according to its boss Stephan Dyckerhoff. In Japan, for example, the first nurse team left after a few months, “overwhelmed by the situation of having to manage themselves,” Dyckerhoff wrote in a guest blog post for Agile Australia. “We now work using a ‘step by step’ approach, encouraging nurses to take more responsibility over time but having a lead nurse and/or general manager in place at the beginning.”

BMJ Open reported something similar in a 2018 study of an English neighbourhood nursing team using an adapted Buurtzorg model. The nurses loved it, the patients loved it, but it messed with the system. “Challenges were reported… in relation to the recognition and support of the concept of self-managing teams within a large bureaucratic healthcare organisation.”

Of course they were: the whole point of Buurtzorg, with its motto of “humanity over bureaucracy,” is to sideline bureaucracy, and that is never going to be popular with management.

There is one glaring absence from Buurtzorg International’s line-up — the United States. A home care organisation modelled on Buurtzorg began in 2014 in Stillwater, Minnesota, with financial support and guidance from the Dutch. It had four nurse employees and cared for its first few home care clients on a private-pay basis, but the team had to deal with multiple payers, each with its own rules and procedures. That made it difficult for nurses to follow the approach of their Dutch counterparts, who do their own billing and therefore make the savings in administration costs that underpin the Dutch organisation. Buurtzorg pulled out of the United States in 2017. De Blok says Americans keep calling him, attracted by Buurtzorg’s growth, but they miss the point. “It is designed on trust… not to make as much profit as possible.”

But he’s not suggesting everyone Buurtzorg partners with must be a not-for-profit. In fact, Neighbourhood Care is owned by Future Proof Australia, a management services firm run by Stroobach, who has a background in medical informatics, and his partner Brett Parker, an accountant. It needs to make a profit to survive, but Stroobach volunteers that the NDIS is very generously funded — and in aged care there’s a huge demand for home care services.

In 2017–18, almost a million Australians accessed home care services (versus 200,000 people living permanently in residential aged care), and part of the federal government’s response to the aged care royal commission was additional funding to deal with the 100,000-strong waiting list for home care packages. What the royal commission failed to do, according to Wollongong University’s Anita Westera and her colleague Kathy Eagar, was to “make recommendations to end excessive price gouging, particularly in home care, and to regulate excessive profit.”

This is not to suggest that Buurtzorg is looking to make money from vulnerable older Australians, but simply to note that the model — rather like the Montessori education model — is open to adaptation and interpretation, both within aged care and more broadly. All over the world, people are trying to rewire power structures. People like New York–based digital activist Jeremy Heimans, for example, who is better known in Australia as the founder of Get Up! He frequently uses Buurtzorg to describe what the future of work looks like. “What Buurtzorg gets right is it puts human beings front and centre,” he wrote in a piece published by LinkedIn.

A lot of people know intuitively that NPM isn’t working — that “you can’t successfully micromanage delivery of complex services from the centre,” as one former senior public servant put it to me — but don’t necessarily have the language to express what an alternative would look like.

Thea Snow, who runs the Melbourne office of the London-based Centre for Public Impact, has met some of these people in webinars she’s run throughout 2020–21 in conjunction with the Australia and New Zealand School of Government. Thousands of public servants have signed up to explore themes like humble leadership, power sharing, systemic thinking and meaningful measurement. They’re not only from  the social services, but also from areas like defence, fisheries, agriculture and planning.

For Snow — as for others — Buurtzorg represents “something bigger, a movement. It is about a new belief in what the role of government is, what frontline works are, how citizens interact with government… It is not mainstream, but I feel energised and positive about the ways this conversation is attracting people who are extremely passionate about reimagining government.”

As for Arnold Stroobach, he’s walking the talk over in the west. “We have similar conditions in Australia as there were in 2006 when Jos de Blok started Buurtzorg… What I hope is that just like in the Netherlands, it becomes a dominant model in healthcare with everyone working in the Buurtzorg way.” •

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

The post Coffee first, then care appeared first on Inside Story.

And so, during the bitter harvest of the Covid-19 pandemic, we have gathered the pedagogical fruits of our discontent. We’ve discovered a new-found appreciation of nature — flamboyant skies, the ruffled silk of the ocean in the early morning — we’ve become unnervingly excited about seeing our friends, and we’ve developed empathy for people on the margins. Reliant on seemingly arbitrary decisions by immigration department officials to reconnect with loved ones overseas, we might have a better understanding of the experiences of migrants.

And if we were among the one in five Australians who experienced high or very high levels of psychological distress during the pandemic, or if we have care of someone with a mental illness, we now have some experience of what it’s like to navigate Australia’s broken mental health system. We now know what our system of “care in the community” really feels like.

Australians went into the pandemic with a mental health system that was already shattered. As the recent Victorian royal commission found, funding has not kept up with demand in Victoria, nor in any other Australian state. If you are in need of care today you are unlikely to be able to access treatment close to your home, and you’re likely to be prescribed medication rather than therapy. And if you reach out to a hospital for help, you will probably be told you’re not sick enough to be given one of the few psychiatric beds available. The threshold for accessing mental health services is impossibly high, with many people effectively told that they’re “not suicidal enough.”

If your symptoms are severe, you may be among those whose first encounter is not with a psychologist but with the police, and you may be one of the significant proportion of psychiatric admissions driven to hospital in a paddy wagon. In Victoria, you would have to wait more than eight hours to receive a psychiatric care bed, if there’s room at all. You may have been given compulsory treatment or placed in seclusion or restraint (all of which are routinely used), and you would be released not when you’ve recovered but when your symptoms have abated. Once outside, it’s likely that the women in your life will care for you, unpaid and unrecognised. Care in the community, after all, has almost always meant care by women.

Whether we are experiencing garden-variety Covid flatness (pondering whether R U OK? Day should be called R U Meh? Day), low-level anxiety about government incompetence, or depression at the interminable sameness of our days, or we have reached out for help only to receive a script for pharmaceuticals in place of a professional, we are being given first-hand insights into our mental health system. And this is leading to questions about how our system became so dysfunctional and what can be done.

The Victorian royal commission tells us that “the system’s failures can be linked to its origins”:

In the 19th and 20th centuries, people living with mental illness were separated from the rest of the community and housed in institutions. These institutions began to be dismantled from the 1980s, with a desire to move towards a community-based model of care. But while there has been social change since then, such as a strengthened focus on protecting and promoting human rights and the consumer movement, Victoria’s mental health system has not kept pace.

It’s a common progressivist view of the history of mental healthcare, which starts in the frightful Victorian era, when the mad were locked away in gloomy asylums with narrow windows and long, cold corridors to be shackled, whipped and straitjacketed. Over time, we discovered that people with mental illness were not demons but suffered from medical conditions. By the late twentieth century we had transformed “lunatics” into rights-bearing citizens, patients into consumers, institutions into community care, and straitjackets into pills. The asylum belonged to the monstrous past.

In fact, the history is far more complicated. “It’s not clear whether [the asylum’s] disappearance is a victory for mental health,” writes historian Barbara Taylor in The Last Asylum, a book that weaves the history of deinstitutionalisation into her own experience of being admitted to a British mental asylum. The asylum that Taylor refers to was not the overcrowded, underfunded cemetery for the mad that it had become by the middle of the twentieth century, but the well-regulated refuge for troubled minds that Victorian-era reformers first imagined.

Britain’s self-supporting community of Colney Hatch was a good example. “Its 165-acre site boasted a large farm, orchards, gardens, stables, gasworks, waterworks, laundries, bakeries, and craft workshops manufacturing everything from brushes and beds to boots and clothing of all varieties,” writes Taylor. “Most of the asylum’s food and, by the end of the nineteenth century, all of its clothing were produced on-site by the patients… So idyllic did all this appear that it left more than one mid-nineteenth-century observer convinced that Colney Hatch was a model environment for the sane as well as the insane.”

Australia’s first asylum, built in 1811, was designed to sequester “lunatics” deemed “dangerous,” and it wasn’t until a series of inquiries into lunacy law between 1855 and 1868 that a kind of moral enlightenment swept across asylum administration. The focus shifted to moral therapy and medical intervention: the asylum was to be a refuge and a place of reform for troubled minds. The splendid architectural remains of this vision can be seen most clearly today in Callan Park in Sydney, with its pavilion-style layout, views of the Blue Mountains, lofty, airy rooms, summer breezes and landscaped courtyards.

By the twentieth century the language of madness had changed. Eugenicist pessimism usurped Enlightenment optimism and developed treatments to suit its miserable science. With the problem now assumed to be one of genetic defects, the solutions shifted from the social to the physical. Psychiatry shook off the embarrassment of its parentage (the medieval theory of “humours”) and transformed itself into a branch of medicine, with remedies to suit.

Sterilisation, electroconvulsive therapy, prefrontal lobotomies and insulin shock therapy were introduced in the first half of the twentieth century. As psychiatrists imagined more pathologies, the constituency expanded and changed from itinerant men to housewives and servants. As Sydney University historian Stephen Garton has written, this was not a progressive march towards humanitarian care of the mentally ill: “In fact, the older moral therapeutics of the nineteenth century resulted in more humane treatment, less resort to restraint and higher rates of recovery than the psychiatric hospital of the mid twentieth century.”

By the 1960s, when the anti-psychiatry and civil rights movements pushed for the closure of asylums and the right of people with mental illness to live in the community, reform was overdue. Cunningham Dax, the reformer who oversaw deinstitutionalisation in Australia, established a network of medical and rehabilitation services delivered in institutional settings, day hospitals, general practices, sheltered workshops and hospital out-patient departments.

This progressive therapeutic model of community care continued into the 1970s under prime minister Gough Whitlam, who funded modern psychiatric hospitals and innovative forms of treatment, including group therapy and resocialisation programs run by psychologists, occupational therapists and social workers. As psychiatrist John Cade wrote in 1979, these modern institutions were so pleasant that “it is hardly to be wondered at that some people… are resistant to the thought of discharge from such an environment.”

The changes came in 1983 with the Richmond report on institutional care in New South Wales. The report outlined a framework for closing standalone psychiatric hospitals and “mainstreaming” mental health services into an integrated hospital system. Change swept through the system.

Just a decade later, the Burdekin report provided the first official assessment of the catastrophic effects of “community care.” Ever more damning reports, like the one released by the recent Victorian royal commission, have followed. As social historian Virginia Berridge has argued, care in the community has become care by the community.

As we, or family members, or other people we know suffer mental illness because of the pandemic, it seems a good time to try to imagine what a compassionate mental health system would look like. And this means engaging with a more complicated past than suggested by our caricatures of asylums. Is the freedom to be cared for at home by an overburdened family member with no expertise and no financial or medical support a liberty or a loss?

Rather than promoting individualised solutions to mental health problems — mindfulness, R U OK? days, exercise, medication or massages — why not demand that today’s governments spend the same kind of money that Victorian-era governments devoted to asylums or Gough Whitlam put into community care? And why not begin tackling the social pressures that give rise to psychological distress — such as job losses, wage stagnation, housing costs, discrimination, climate change, and fear of violence — rather than pathologising people for their quite rational responses to an increasingly unwell world? •

The post Troubled minds appeared first on Inside Story.

Back in the 1960s and 1970s, when our population was around half its current size, more than 3000 people died every year on Australian roads. After a long series of interventions, beginning with seatbelt laws in Victoria, the annual number of deaths has fallen to around 1000, despite a significant rise in population. The likelihood of dying on the roads today is about one-sixth what it was fifty years ago.

This is not primarily the result of improvements in vehicle safety. In the United States, a comparable country in many ways, the number of deaths has remained broadly stable since the early 1960s, approximately halving relative to population. There, road safety laws are enforced much less rigorously.

Is Australia’s lower level of road deaths acceptable? Victoria’s Transport Accident Commission doesn’t think so, pointing out the hidden implications of the language we use. “The problem with talking about ‘road toll,’” it says, “is that it implies that road trauma is an acceptable cost of having roads. A toll is the price we pay for using something — with toll roads, for example, it’s a few dollars.”

The view that road deaths are still unacceptably high is embodied in Vision Zero, a campaign that has set a target of no road deaths in all major capital city CBD areas and on high-volume highways by 2030, and no road deaths anywhere in Australia by 2050.

Why such a long time? Partly, it’s because making roads fatality-free is a difficult business requiring significant investment. But in large measure, it’s because governments have moved slowly out of a well-grounded fear of provoking resistance from people with the same attitudes as those now denouncing Zero Covid.

Virtually all the safety measures introduced since 1970 (compulsory seatbelts, random breath testing, speed traps, and limits on young drivers) could have been implemented fifty years ago if we had had the collective will. Instead, they were introduced incrementally, gradually wearing down the resistance of those for whom freedom to drive dangerously was more important than their own lives or those of others.

Exactly the same points may be made in relation to smoking. Fifty years ago, around half of all Australian men smoked and women were rapidly catching up. A long series of measures, including restricting advertising, banning smoking in public places and, most recently, gruesome plain packaging, have pushed the proportion of adult Australians who smoke below 15 per cent. Rates of lung cancer mortality for men peaked around 1980, but the turnaround was much slower for women and their mortality (always lower than for men) has only just begun to decline.

Again, our progress was slow not because the task was impossible. We have chosen to live with high death rates, and to reduce them only gradually, because of the resistance from some smokers (others were keen to quit and welcomed pressure to do so) and from the corporations that profited from them. Plans to end smoking and the deaths it causes are now on the policy agenda. They include making cigarettes prescription-only and raising the smoking age steadily over time until it is effectively illegal for everyone.

As for domestic violence, until relatively recently we didn’t so much choose to live with high death rates; rather, we ignored them altogether. We didn’t even have a standardised system of collecting and reporting data. But now that the problem is out in the open, no one seems to be saying that Australian women should “live with” domestic violence and accept that some will die.

With those examples in mind, let’s go back to influenza. As with the other examples listed above, we have accepted hundreds of flu deaths as one of those things we need to live with. There was no campaign to “stop the spread.” Vaccination wasn’t even free for most people. The government paid for vaccinations for the most vulnerable groups but seemed not to recognise the nature of an infectious disease — if you want to protect the vulnerable, you need to vaccinate everybody. Before the pandemic, vaccination wasn’t even compulsory for aged care workers.

For the past two winters, however, the annual flu season effectively hasn’t happened. That reflected the combined effects of closed borders, improvements in handwashing and other prevention measures, and a reaction against the culture of “presenteeism” or, in the slogan promoted by Johnson & Johnson’s Codral brand, “soldiering on” (in other words, going to work when you’re ill).

There’s every reason to think we could permanently suppress seasonal influenza without recourse to drastic measures like lockdowns. The first step would be to mandate flu vaccination wherever Covid vaccination is required (for international arrivals and high-contact workers, and as part of any vaccine passport scheme).

Next, we would introduce a continuing campaign to ensure that adults don’t go to work with flu and that sick children (major spreaders of flu) stay home from school. That will only be feasible with more comprehensive sick leave, including carer’s leave.

Plenty of people will no doubt argue that this is all too burdensome, just as they have in response to all sorts of policies to reduce avoidable deaths, and perhaps they will have some success. But they should not be allowed to get away with using weak policy in relation to one deadly danger as grounds for adopting similar policies across the board. •

The post What about other avoidable deaths? appeared first on Inside Story.

For more than a year, Australia’s Covid-19 response has been one of aggressive suppression. State governments did the heavy lifting using border closures and lockdowns to reduce population mixing, and testing and tracing to chase down outbreaks. Then, on 2 July this year, national cabinet agreed to a plan for moving out of aggressive suppression as soon as vaccination rates have sufficiently reduced the risk of hospitalisation rather than of transmission.

Neither the target vaccination rates nor the underlying modelling were made public when the plan was released. As the details have progressively come to light, national cabinet has had to contend with a markedly deteriorating outlook. In retrospect, the end of June was the high-water mark of optimism that Australia could avoid the worst of the pandemic. For ten months, local flareups had been contained, with daily cases rarely reaching double figures and shut down rapidly. Enough time seemed available to make up for a slow start and unfortunate choices in vaccine acquisition, with mRNA vaccine supplies ramping up later in the year — Pfizer/BioNTech progressively from midyear and Moderna from November.

But the writing was already on the wall. “We’re in trouble, now we know the strain is Delta,” observed UNSW epidemiologist Mary-Louise McLaws of the emerging Sydney cluster on 18 June. On the same day the World Health Organization’s chief scientist warned that the Delta variant was “well on its way to becoming the dominant variant globally because of its significantly increased transmissibility.”

Delta is quantitively rather than qualitatively different from its SARS-CoV-2 precursors. Viral load following infection has been measured at 1000 times higher, making it not only more likely to spread but also able to take hold faster, accelerating the onward spread. Children, whose innate immune response kept them largely free of symptomatic disease with earlier strains, are more likely to fall ill.

To some extent, Delta also seems to cause more serious illness and be a little better at evading the protective impact of vaccines. Analysis from Britain, where this variant now overwhelmingly predominates, suggests that hospitalisation is about twice as likely than with the earlier Alpha UK variant. Vaccines still appear to provide around 90 per cent protection against serious illness measured by hospitalisation, with the mRNA vaccines performing slightly better than Oxford/AstraZeneca. But the real-world evidence is still accumulating.

Countries with high vaccination rates — including Britain, the United Arab Emirates, Israel and the United States — have seen surges in Delta-driven infections in recent months. Britain’s two-dose vaccination of the sixteen-plus population has reached 79 per cent, but new daily infections are currently around 40,000, with around a hundred deaths each day.

The Doherty Institute’s model, used by national cabinet to craft the transition plan, was drafted with Delta in mind, drawing on midyear data and models from Britain. But in the absence of more definitive data, it assumed that Delta variants would not lead to higher rates of severe disease than do Alpha variants.

The discussion about Australia’s transition has focused on vaccination thresholds: a solvable problem of aligning supply, logistics and willingness. Vaccine hesitancy has been overblown — an ANU survey shows hardcore unwillingness at 5.3 per cent in mid 2020, in the first phase of excitement at vaccine success, rising to 7.7 per cent in January 2021 as safety questions began to be raised. The small but real risks associated with the Oxford/AstraZeneca vaccine sensibly deterred its use when outbreaks were low, especially among young people; those risks have not disappeared, but the risk calculus has changed with more likelihood of encountering Covid-19. There is every indication that the Australian population has understood the risks and constraints of the vaccination program very well.

But it would be a mistake to imagine that 80 per cent vaccination levels will snap Australia back to a pre-Covid future.

The Delta variant will not be the last to emerge. Natural selection is a cruel master. Delta’s superior transmissibility allowed it to dominate in much of the world, although in Latin America the Lambda variant had already taken much of the territory. Some have suggested that Delta is as transmissible as the virus will ever get, but the balance of opinion suggests that would be foolish optimism. One evolutionary pressure is to transmit more easily, another is to evade immunity.

The race to develop more effective vaccines — including ones that better protect against emerging variants — will continue. Some will be based on mRNA platforms, the most outstanding of the scientific breakthroughs the pandemic has produced. But mRNA vaccine manufacture is formidably difficult, and Australia has only belatedly moved towards domestic production, with Victoria’s “mRNA Victoria” kicked off by $50 million startup funding in May, and a federal government call for market-based proposals.

The need for vaccination to keep ahead of viral variation emphatically goes beyond national borders. Variants emerge in the petri dish of rampant transmission, a vicious cycle that is fuelled by vaccine shortages. Australia’s schedule swap with Singapore for half a million Pfizer/BioNTech doses came just days after the heads of the International Monetary Fund, the World Bank, the World Trade Organization and the World Health Organization called for schedule swaps to be directed to the global COVAX facility and the African Vaccine Acquisition Trust.

Nor are vaccines the only game in town. The medical management of Covid-19 cases has improved, but effective therapies are still few and far between. Antibody therapy, one of the few positive approaches, is inherently complex and expensive. The evidentiary debacles involving hydroxychloroquine and ivermectin have soured the therapeutics landscape, but the inevitability of endemic Covid-19 will demand new drugs.

A future in which vaccination reduces but doesn’t eliminate hospitalisation will also demand more sophisticated social technologies to reduce risk. The early burst of techno-enthusiasm for apps — from contact tracing to remote learning and working — has faded to a weary resignation that the technologies will not live up to the hype. Real progress is a more mundane slog.

More trust will need to be placed in communities, empowering them to make risk decisions. Rapid antigen testing has been a mainstay of Germany’s Covid monitoring, offering cheap and effective detection of infection when it matters — when people are most infectious. Aldi has stocked self-test kits there; why not in Australia? The stranglehold of vested interests — pathology labs, medical providers — needs to be loosened in the interests of a flourishing and nuanced approach to risk management.

Neat dichotomies are the enemy of the type of adaptability that complex systems need to deal with new and uncertain threats. Covid-19 has not set up a contest between freedom and imprisonment. It has created an uncomfortable and difficult reality that will continue to change. Making the best of it is the best we can hope for. •

The post Managing the transition appeared first on Inside Story.

There’s no chance of the plan’s being revived this side of the election given how united people with disabilities have become in expressing their outrage with the government. Or, as one of the architects of the scheme, John Walsh, puts it: “I can’t begin to say how angry I am about the way Australian governments collectively have let down people with disabilities.” Until recently, Walsh served on the board of the administering body, the National Disability Insurance Agency.

Yet, unlike most in the disability sector, Walsh agrees with independent assessments of the support NDIS participants receive, if not necessarily in the form the government was planning. The assessments were proposed by the Productivity Commission in its landmark 2011 report recommending the introduction of the NDIS — the inquiry on which Walsh served as associate commissioner. The problem now is that the government has lost the trust of a disability community that suspects its motives at every turn.

To recap, the NDIS, introduced by the Gillard government and supported by all parties in parliament, is the biggest social policy reform since Medicare. It replaced the hotchpotch of federal and state government arrangements described by the Productivity Commission as “underfunded, unfair, fragmented and inefficient.” And it has made a real difference. According to Bruce Bonyhady, head of the Melbourne Disability Institute at Melbourne University and another architect of the NDIS, “it is a scheme that is doing extraordinarily positive things for hundreds of thousands of people with disabilities.” More than 50 per cent of participants were receiving no assistance at all before it started, he adds.

Given that, Walsh’s anger requires some explanation. A quadriplegic who was heading for a career as an astrophysicist before a football accident at the age of twenty, he spent decades working as an actuary on no-fault state government accident compensation schemes. Their underlying principle of social insurance informed the development of the NDIS.

The Productivity Commission proposed much more than a welfare program: people would be given control over their affairs, choosing the supports they needed to live more independently, find employment and generally lead fulfilling lives. Its insurance principles stemmed from the reality that the lottery of life meant that any Australian could face a disability, thus giving us all a stake in managing this risk through the tax system. Treating it as insurance also meant taking a lifetime approach, emphasising early intervention to save higher costs later, and increasing the opportunities, including employment, for people with disabilities and for their carers. In short, its benefits to the broader economy, as well as to individuals, would be substantial.

Walsh’s beef is that this vision has been lost. “I don’t think the NDIS has ever been implemented,” he says. “Perhaps 10 per cent of people are self-managing” — given control of a package of funding to pay for agreed supports — “which is the real opportunity for people to be doing what was intended by the scheme.”

Meanwhile, he says, 40 per cent of NDIS funding is provided for the 7 per cent of people who live in group homes under the Supported Independent Living program, which was transferred from state and territory governments. “Many participants in SIL continue to have little choice or control over their circumstances but nevertheless have 86 per cent of their committed supports — in excess of $300,000 per person per annum — consumed on their behalf,” he told the joint federal parliamentary committee on the NDIS.

A substantial part of the rest of the NDIS budget goes to medical therapy for children. “This has become a much larger part than it was ever designed to be,” he tells me, and the figures bear him out. Of the 468,692 people covered by the NDIS, 193,814 — more than four in ten — are younger than fifteen. Autism (at all ages, although mostly among children) accounts for 146,412 participants compared with the Productivity Commission’s original estimate of about 75,000. Another 53,264 fall into the category of developmental delay. With the NDIS estimated to grow another 30 per cent before it is fully operational, these figures will continue to increase.

“It is not difficult to get an autism diagnosis,” says Walsh. “It’s a spectrum and there are many children who have signs of being on the spectrum but don’t necessarily need an individual support package to go and see a therapist.” For those in the disability sector, this is a brave statement, guaranteed to bring the wrath of parents on his head. But others agree with him and are prepared to say so. “A large number of children are being diagnosed with autism who don’t actually have it,” paediatrician David Roberts, a former president of the WA branch of the Australian Medical Association, told Inside Story in 2017.

“Over the past ten years,” said Roberts, “I have run across cases in the hundreds where the diagnosis has been made but the assessment has been conducted improperly and where there have been conflicts of interest in the diagnosticians.” Roberts hasn’t changed his view, telling me the rate of diagnoses has increased in the last four years. For a parent with a child on the autism spectrum or with developmental delay, though, an NDIS plan with guaranteed funding is a godsend, given the few government-provided alternatives.

Despite its problems, Bonyhady describes the NDIS as “an oasis in the desert.” An estimated 4.5 million Australians have some form of disability. The scheme was designed to cater for a minority who need the most support, with the Productivity Commission outlining a comprehensive strategy for the remainder, including mainstream services and community support. But funding for most of the lower-level programs, provided mainly by the states, has been withdrawn, so it is hardly surprising that people are prepared to move heaven and earth to get into the NDIS.

This is where the elephant enters the room. According to the latest “financial sustainability” report by actuaries, the scheme will cost a projected $28.1 billion this financial year, which is some $4.4 billion above the Productivity Commission’s 2017 costing for this year. By 2024–25, the actuaries project a cost of almost $41 billion — $12.2 billion more than the commission’s estimate — and by 2029–30, $60.3 billion, or $22.2 billion higher. The main contributors to the escalation are more people than anticipated entering the scheme, fewer leaving and average payments increasing by 12.5 per cent a year.

If the figures look scary, at least to budget-minded people, that’s precisely what the government intended when it released the report a few days before this month’s meeting of state and federal ministers. The idea was to concentrate minds on the need to cut costs.

It didn’t work, with the states and territories rejecting independent assessments and demanding more information about the financial assumptions used. There was some justification for their scepticism. Bonyhady says that up to October last year the government and the administering agency, the NDIA, were saying that the cost projections were in line with the Productivity Commission’s estimates except for two factors not taken into account in its calculations — the subsequent broadening of the definition of developmental delay in children, and the costs of people over sixty-five. While this older age group is not eligible for NDIS assistance, those who reach that age when they are already in the scheme continue to be covered.

Bonyhady says that new estimates were incorporated in this year’s May budget, followed by the actuaries’ report showing further increases. “The numbers just don’t change that quickly. It is very clear that there are now very different assumptions being built into the estimates. These are very complicated calculations, with literally hundreds, if not thousands of assumptions that go into these cost projections. It is impossible to know what to make of these numbers until one sees the detailed models and data.”

The government has stonewalled attempts by Bonyhady and others to see this material. Following the latest ministerial meeting, Linda Reynolds, the federal minister for the NDIS, promised to respond to state and territory ministers’ requests for more information on the costings. Still, the reality is that warnings from the auditors about cost blowouts were made as long as five years ago but have been ignored.

Even if Reynolds ends up convincing the states and territories, the federal government has lost the main weapon in its armoury — independent assessments. Rather than the present system of doctors and other health professionals familiar with the person’s condition helping draw up individual funding plans, the government wanted an allied health professional, unknown to the person, to assess the support he or she needed. This would be done in a session of up to three hours, using a checklist meant to even the playing field of assistance people received. It would overcome the “empathy bias” said to be inflating the plans that participants receive.

Whatever logic applies to such a change, the disability sector quickly saw it as a threat — a cookie-cutter approach with the main aim of saving money. Bonyhady gave it the damning label of “robo-planning,” a reminder of the disastrous robodebt scheme that saw welfare recipients pursued for debts through a faulty computer program that routinely assessed debts where little or no money was owed. His point is that it relied on a single assessment at a preset time using a checklist, when we know that  an accurate picture of disability  can only be obtained by a multidisciplinary assessment taken in multiple settings.

Moreover, one of the guiding principles of the NDIS was supposed to be plans tailored to individuals and starting with their goals. “The intention was that people get packages and flexibility in the use of their packages,” says John Walsh. “That cannot happen [under the present system] unless we are prepared to wear the cost of the scheme escalating to $40 billion. I don’t think the government will do that in a hurry.” He points to the experience of injury compensation schemes in Australia and New Zealand, where entitlements without independent assessments threat-ened the sustainability of the schemes, leading ultimately to restrictions on eligibility and benefits.

Bruce Bonyhady argues that participants’ goals are “absolutely critical to the culture of the NDIS.” As he wrote in a submission to the NDIA, “The focus is, and must continue to be, on what people with disability can do and the support required to exercise their full citizenship rather than what they cannot do.”

There are indeed some unfortunate parallels with robodebt. The government has focused increasingly on cutting costs, but enough examples have emerged of the government misdirecting money — from misspent JobKeeper dollars to sports rorts and commuter car parks — to raise the hackles of people with disabilities.

As well, the government has taken a hard-nosed approach to complaints about unfair treatment, again reminiscent of how the government often took robodebt cases to the brink before conceding that the Administrative Appeals Tribunal was unlikely to find in its favour. According to the NDIA’S figures, of the 3721 AAT cases closed by the end of last year, 3641 had been resolved before the hearing. Often the resolution came after people had spent enormous amounts of time and money, says Bonyhady, and in the vast majority of cases the NDIA conceded.

“All of these settlements are subject to confidentiality so they don’t set a precedent,” says Bonyhady. “The NDIA pushes it all the way in the hope that individuals will give up and then, if people push it to the point where they get to the AAT hearing, they literally settle on the steps.” Of the eighty NDIS cases that did go to a hearing, the AAT found against the government in forty-two. Proposals within the government for expanded debt-recovery powers have more echoes of robodebt.

Whether or not the latest actuaries’ figures are anywhere near accurate, there should be no argument about governments funding the NDIS generously. As the Productivity Commission put it in its 2011 report, “were government to be starting with a blank slate in determining its funding priorities, there would be a strong rationale for provision of disability services to be one of its highest spending priorities.” Nor is the current federal government in a strong position to argue that it is spending our money wisely and with restraint.

Rather, the question is whether any government would be prepared to fund a continuing rapid increase given contending demands. In the wake of the royal commission findings, should the government spend less on aged care and more on the NDIS? These choices will have to be made, whether we like it or not.

By giving the states and territories an effective veto power over major decisions, the current structure includes a safeguard against drastic cuts. But the states also are responsible for stumping up almost half the funding for the NDIS, although the increase in their financial contribution is capped at 4 per cent a year, with the federal government obliged to pay for the rest.

The issue of escalating costs will confront Labor if it returns to government any time soon. Shadow disability minister Bill Shorten, who helped create the political momentum for the scheme when the party was last in government, casts doubt on the claims of funding blowouts but nevertheless concedes some cost overruns. He blames it on such things as the $288 million the NDIA spent on consultants and contract staff in 2019, and the $17 million for legal expenses to fight cases in the AAT. But that still leaves a funding gap of billions of dollars.

Meanwhile, Bruce Bonyhady has developed a detailed alternative to the now-abandoned independent assessments and offered to work with the government to implement it. People with disabilities would be given a genuine say in the process, and the starting point would be the goals of individuals. Any questionnaires used for assessments would be tested and feedback sought, and expert reports would be considered. The emphasis would be on multidisciplinary teams conducting assessments, if necessary in multiple settings. Participants would be able to use their funding more flexibly, with a minimum of fixed categories.

The government has yet to respond. •

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

The post Is this the NDIS’s robodebt moment? appeared first on Inside Story.

Over time, though, lockdowns took on a life of their own. Victoria locked down for 112 days in the second wave, and then circuit-breaker lockdowns proliferated across the country, sometimes triggered by a single quarantine worker in the community regardless of any evidence of transmission. We didn’t just want to flatten the curve; we wanted Covid-zero.

In Victoria, the second wave quickly followed the first, after the first of many crossovers from returned travellers in quarantine. Cases reached a daily average of 150 before restrictions were again introduced. But this outbreak was different: the virus had made its way into workplaces, healthcare facilities and aged care accommodation and would be harder to contain. Contact tracing systems that had barely been tested were quickly overwhelmed.

Masks were introduced progressively across Victoria from late July, and Monash University modelling has since shown that they were the game changer, reducing transmission by 40 per cent. Nonetheless, with daily case numbers high, Victoria’s health department moved to more extreme stage four restrictions, including movement limits, night curfews and the “ring of steel” around Melbourne.

Why didn’t the lockdown work as expected in the second wave? As it turns out, it was merely holding transmission potential extremely low in the community while the virus was being fuelled by outbreaks in essential workplaces and healthcare. New South Wales is following the same pattern now, with sufficient low-level spread between workplaces and households to keep the outbreak alive. Without this reseeding, both waves might have died out within weeks.

As Victoria moved further into the second wave, restrictions continued to tighten. We are yet to see any formal evaluation of the various steps into and out of lockdown in Victoria, which would identify what worked then and what might work in the future. Instead, we keep reverting to the same style of lockdown as if one size fits all.

Apart from Adelaide’s first circuit-breaker, rapid short lockdowns have been triggered by concern over new variants brought in by returned travellers. With the Alpha variant, first referred to as the UK strain, we were almost back at square one, facing an infectious agent that we were still coming to understand and erring on the side of caution to close down an outbreak before it had even started. But we did learn that our usual test, trace and isolate approaches still worked against the new variant. Because it was 50 per cent more infectious, we just needed to be more meticulous and efficient.

Many were surprised when potential outbreaks in Brisbane and later in Perth fizzled out with little or no community transmission. But Alpha, like its ancestral strains, spreads in fits and starts. Only 10 to 20 per cent of cases are responsible for the majority of the next generation of spread, with the rest infecting either no one, or just a small number of close contacts. Having quickly been deemed successes, these lockdowns were used as a model without any formal evaluation to guide when, how and where they should be used.

Then came Delta, which is twice as infectious and appears to travel faster than our contact tracing. A person can become infectious within forty-eight hours of exposure to an infectious case — in one documented instance, as little as thirty hours. With transmission occurring despite early identification of the threat and strict responses, we have seen four states and the Northern Territory head into lockdown.

By Wednesday this week, New South Wales had 2574 cases linked to its active Delta outbreak, with Victoria on 198 and South Australia nineteen. Initially New South Wales dealt well with the outbreak, which was discovered within the first few days after a major spreader event at Bondi Junction Westfield. But although contacts were traced quickly, many had already been infectious for a day or so. (This fits with data from China, where Delta cases typically have become infectious two days sooner than for earlier strains.)

When the same pattern was seen in Victoria, lockdown was introduced six days earlier in the cycle. South Australia acted with even more haste.

This latest series of June–July lockdowns highlight how inconsistent we remain. Some jurisdictions emulate others, some use their own design. Early action is clearly the key, so we once again find ourselves considering lockdowns as a first line of defence at the first sign of Delta in the community.

Until enough of us are vaccinated to take the pressure off contact tracers, this is likely to be our unpredictable path for a few months yet. But we can at least urge health departments to evaluate each lockdown in order to guide tailored, consistent and above all evidence-based measures. •

The post Does one size fit all? appeared first on Inside Story.

All is not lost for the government. The media bandwagon has changed gears in recent days and, possibly feeling pity for a regime so unable to present its citizens with clear public health messages, seems to have decided to take on the job itself. To take just one example: this week’s episode of Media Watch was largely devoted to countering the “beat-up” over AstraZeneca. It reported on other media but did so in a way that made it clear Paul Barry thinks we should stop worrying and learn to love the jab. It was essentially an op-ed.

The prospects for a government that can rely on help of this kind from the supposedly left-leaning ABC should not be written off. But it doesn’t deserve such help. The vaccination disaster is the worst national public policy failure in modern Australian history, rivalled only by Paul Keating’s early-1990s recession “we had to have.”

Australia will eventually complete its vaccination program — presumably, some time in 2022 — and it might even manage to do so without the loss of several hundred more lives to Covid-19. But the casual approach we have seen so far, especially in getting aged care workers vaccinated, means that we are far from out of the woods. Still, it is too easy to blame the nation’s vaccination ordeal on an incompetent government and its publicity-obsessed leader. There is more to it than the frailties of any particular government.

What we have seen in recent months is the workings of a hollowed-out national government. It has decent systems — run by the Australian Taxation Office and Centrelink — for shuffling money around, provided you are not a robodebt victim. It has some agencies that have been able to undertake their regulatory work effectively, helping to keep the economy going and supporting efforts to manage public health.

But when it comes to hands-on service delivery, the federal government now seems rather hopeless. It is incomprehensible that it placed so many eggs in the AstraZeneca basket; no explanation has ever been offered, and many journalists seem to have the attention span of a goldfish in such matters.

It was not always the case that federal governments were so distinguished by what they could not do. Writing a quarter of a century ago, the historian A.T. Ross showed that in the interwar period the federal government pursued a defence policy based on the development of a local capability in munitions production — called “self-containment” — so that Australia would not depend on overseas supply. At the heart of the effort was a Munitions Supply Board, established in 1921, which would provide incentives for companies to produce locally by funding research and development. It even set up government factories in priority areas, to pioneer complex production processes. Ross went so far as to argue that Australia was saved from invasion in 1942 by its industrialisation more than by the United States of America.

Those were the days when federal governments held the hose. There is an even more telling example for our own times: the Spanish influenza pandemic of 1919. The effectiveness of the government-led vaccination program is open to question, especially as it was another decade or more before flu was recognised to be viral rather than bacterial, but the ambition is worth recalling.

Even before the Spanish flu arrived in Australia, the Commonwealth Serum Laboratories — established as recently as 1916 — was working on a vaccine. CSL had collected sputum from returning soldiers who had already been exposed to the outbreak, and used agar — derived from a Japanese seaweed — to grow the bacillus. The vaccine comprised a mixture of chemically killed bacteria, some recovered from the deceased victims of earlier flu outbreaks.

By February 1919 CSL had already distributed more than a million doses, and orders arriving at CSL’s new Parkville premises were being met within twenty-four hours. CSL would eventually produce something like three million doses for a country with a population of only about five million. In Sydney, the Prince Alfred Hospital and the Royal North Shore Hospital were each making a vaccine. Nurses sometimes donated the blood needed to make the product. Vaccine depots were well patronised, and heavy demand did occasionally lead to shortages and the administration of part-doses.

There was some vaccine hesitancy, then as now, but certainly with more reason. The vaccine content was based on guesswork — which was wrong, as it turned out — and the needles were much bigger and really hurt. A Dr Joel, who reported “results which are nothing short of miraculous” for the CSL vaccine among the sailors on his watch as a naval doctor, gave the hesitators short shrift: “Conscientious objectors, if the legislature has not the courage to compel inoculation, should be isolated from the rest of the community, it being pointed out to them that we object not so much to their attempted suicide as to their carrying the disease unmitigated to those who are not tired of life.”

No extensive clinical trials were carried out; nor was there a rigorous approval regime. Governments didn’t need to worry whether one or two in a few hundred thousand recipients might get a blood clot. They did not have the political nightmare of the pink batts saga a few years behind them, a permanent reminder to government that if your efforts to save the country from a global crisis result in the tragic deaths of four citizens, that is all that anyone will recall. Citizens certainly won’t remember the million houses that were successfully insulated, or the carbon emissions reduction achieved. They won’t be convinced by arguments that workers are too often losing their lives on building sites yet no one calls a royal commission to investigate.

Some recent commentary suggests the CSL vaccine might have benefited recipients by boosting their immune systems. In a way, though, whether it worked or not is rather beside the point today. The scientists were operating in the context of extremely limited knowledge about influenza, and they did their best to protect the Australian people, with the rapidly rising capacities of a national government behind them.

The confidence of the Australian federal government of that era of nation-building is striking — as is the contrast with its low ambition and incapacity today, despite its vastly greater size and the massive material, intellectual and technological resources now at its disposal. We should all be alarmed by what the federal government has shown it cannot do — by its incompetence in both words and deeds — as well as by what the present occupants don’t regard as any of their business.

The lesson has relevance to much more than pandemic management. Is it any wonder that people are looking to state governments to protect them, and turning to nutters on the web for health advice? •

The post A little jab, now and then appeared first on Inside Story.

What went wrong? How did a country with an internationally envied record of managing the pandemic and a history of successful vaccination programs come to lag so dreadfully? And what can be done before more Australians die unnecessarily and more lockdowns damage the economy and erode wellbeing?

The evidence shows that the blame rests squarely with the Morrison government and its advisers (assuming their advice is being followed). Only a substantial change in their attitudes, policies and communication efforts will reverse the vaccination trends and enable Australia to open its state and international borders permanently.

Efforts to develop a vaccine against the SARS-CoV-2 coronavirus began early and have been spectacularly successful. By July 2020, when I looked at progress in international vaccine development, 139 vaccines were in development and twenty-six undergoing human trials. Omitting Chinese efforts, at least six vaccines from major pharmaceutical companies were in either phase 2 or phase 3 clinical trials.

By then, the United States, Canada, Britain and other countries were making deals to ensure access to a range of vaccines. The Australian government’s approach was much more cautious; rather than “back every horse in the race,” bets were made on just two vaccines and the new mRNA vaccines were totally ignored.

Scott Morrison’s claim in August that Australians were at the head of the vaccine queue was based on a letter of intent for the purchase of thirty million doses of AstraZeneca vaccine, with CSL to manufacture at least some of these, and a big bet on the University of Queensland vaccine, with a heads of agreement signed with CSL for the production of fifty-one million doses.

There is every reason to believe that these purchasing decisions were based as much on cost considerations as on a need for national self-reliance, and that they ignored advice to ensure access to a full range of vaccine types. The AstraZeneca vaccine costs about US$4 per dose, considerably less than the mRNA vaccines made by Pfizer (US$20) and Moderna (US$32–37), which have more challenging storage and transport requirements. While local production is an admirable goal, it is not clear how CSL could simultaneously manufacture two different vaccines at the same facility given the large-scale production requirements.

It is public knowledge that negotiations between the Department of Health and Pfizer in July 2020 didn’t result in a purchase agreement at that time (that didn’t come until November, with a purchase of ten million doses). Persistent rumours suggested that Australia turned down the possibility of forty million Pfizer doses, to be delivered early in 2021, after haggling over costs and intellectual property.

By the end of February this year Australia was watching with great interest as US president Joe Biden and his team successfully turned around the Trump vaccine rollout fiasco and as Britain and Israel were implementing effective national vaccination campaigns.

Australians were initially happy to wait, even as Biden and Johnson went into overdrive — after all, the situation Down Under was very different, with infections under control and time available for full regulatory approval (rather than emergency authorisation) and planning a gold-standard vaccine rollout.

By this stage Australia had orders for twenty million Pfizer doses to arrive in 2021 and for 3.8 million AstraZeneca doses to be manufactured offshore (300,000 had already arrived), with fifty million more to be manufactured by CSL in Australia. After problems with the molecular clamp technology using HIV-derived proteins, though, there was to be no University of Queensland vaccine. As a result, Australia was now looking for more vaccines but faced a long queue for the Pfizer and Moderna mRNA vaccines, with perhaps as many as a billion doses already spoken for by other nations.

A few lucky Australians, the prime minister among them, had received their first jab. Morrison and Hunt heroically announced a target of four million vaccinations by the end of March and full vaccination by October. With a potential arsenal of seventy million jabs, enough for thirty-five million people, these goals seemed realistic.

But things started to go wrong very quickly. By the beginning of April it was clear that the Morrison government had over-promised and underdelivered. The European Union blocked exports of AstraZeneca vaccine, citing its own needs, and expected supplies were not arriving at vaccination centres. CSL production was under way but not in full swing. The government had already walked back the “all Australians vaccinated by October” pledge on 11 March.

And then, on 8 April, the government announced it had accepted the Australian Technical Advisory Group on Immunisation’s advice that Pfizer should now be the preferred vaccine for people aged under fifty because of the risk of blood clots from the AstraZeneca vaccine.

Since then, the vaccination program has spiralled further out of control, fuelling anger and frustration among state and territory leaders, despair among healthcare providers, and increasing vaccine hesitancy in the population.

The litany of failures is long and growing: unjustifiable delays in vaccinating population groups at highest risk (such as people in aged and disability care and their carers, and remote Indigenous communities); the inability to commit to vaccine deliveries in terms of both timing and quantities; the absence of effective communications and public education campaigns; and, most critically, a lack of transparency in government actions and decisions. All this has been aggravated by failures in hotel quarantine — yet another area of federal government responsibility that has been botched or, more accurately, ignored.

Many of the problems stem from the fact that the federal government (in contrast to state and territory governments) has little or no experience or expertise in delivering health services. Large sums have been spent on contractors and subcontractors to deliver vaccines and consultancy firms to advise on how to do this, often without first going to public tender and with no public scrutiny.

Unable or unwilling to admit to problems and tackle them promptly, the Morrison government has lost all the advantages that accrued from earlier lockdowns. Under its original goal, some twenty-two million doses would have been delivered by now and everyone in the top priority groups would be fully vaccinated. Even under the revised goal, more than ten million doses would be in Australians’ arms. That would have gone a considerable way towards blunting the impact of the Delta variant.

According to this week’s figures, the current vaccination gap is 4.7 million doses. Based on the current seven-day rolling average of 111,600 doses, it will take eleven more months to vaccinate all Australians (including children).

Some efforts have been made to deal with the problems. At the beginning of June, Lieutenant General John Frewen was announced as the head of the National Covid-19 Vaccination Task Force, a step described by one commentator as the federal government defaulting to the one implement it completely controls. Morrison chose to describe this as a “completely new organisational structure for getting a whole-of-government effect on a very big problem” and highlighted this by renaming the taskforce Operation Covid Shield.

Frewen has since released week-by-week vaccine allocations through to the end of the year, which should assist planning in the states and territories. But vaccine supplies will be constrained at least until the end of August, depending on how many people refuse the AstraZeneca vaccine. Supplies may also be affected by continuing outbreaks of infection that increase demand by states and territories over that allocated.

By mid September the supply of some 2.2 million doses each week is expected to be totally made up of mRNA vaccines, both Pfizer and Moderna. Australia’s initial twenty million Pfizer doses have apparently been brought forward a little and an extra twenty million have been ordered, to arrive before December. An agreement to secure twenty-five million doses of Moderna was announced in May, but the vaccine is yet to be approved by the Therapeutic Goods Administration. An agreement to purchase Novavax (a protein-based vaccine) also apparently exists; but phase 3 clinical trials have yet to conclude, so hopes for its availability in 2021 are very optimistic.

The rollout is now heavily reliant on state vaccination centres, general practitioners and Commonwealth-funded GP respiratory clinics. The case has been made that significantly more GPs need to be recruited to the Pfizer program, that more pharmacies should be involved, and that urgent attention must be given to vaccinating remote Indigenous communities.

The government’s medical experts have done a terrible job of allaying fears about the risks of vaccination and stressing the urgency of getting completely vaccinated, leaving opportunities for misunderstandings and false anti-vaccine claims. Scott Morrison’s “it’s not a race” rhetoric further clouded the message.

Until now, the federal government has made a virtue of following expert advice, even if that advice has not been well-communicated. But Morrison’s recent statement that people under forty could access AstraZeneca vaccine after consultation with their doctor — made in defiance of expert advice, without any input from national cabinet, and ahead of any consultation with the medical community — represents a major departure, worsening vaccine confusion and hesitancy and blindsiding GPs.

Meanwhile, Morrison and his ministers misrepresent the situation in Britain, for instance, by claiming that high rates of vaccination have not prevented infections and hospitalisations from the Delta virus. This ignores the reality that, while Delta infections are increasing, only 7.8 per cent of new Delta cases are among double-vaccinated Britons. Only very small numbers of vaccinated people are hospitalised and dying in the United States, too.

Further evidence about what vaccination can achieve can be found much closer to home in the results of NSW tracking and tracing. After a party in Western Sydney — described as a superspreader event — twenty-four of the thirty attendees tested positive for Covid-19. The remaining six were all vaccinated.

Any delay in getting Australians fully vaccinated inevitably hinders our ability to provide excess vaccines to countries in the Pacific and Southeast Asia. Morrison has said he remains committed to ensuring early vaccine access for these neighbouring nations through commitments at the G7 and through COVAX, the international scheme to ensure equitable access to Covid-19 vaccines.

In his press conference after this week’s national cabinet meeting, Scott Morrison said he was “very confident that Australians won’t give in to the frustration, that they will continue to show the great application and effort and patience that we know is required of all of us… We’ve got to keep going Australia.” The surest way to have Australians “keep going” is for the government to get going. At the moment it is mired in a mess of its own making. •

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

The post How we tumbled down the Covid-19 league table appeared first on Inside Story.

The changes mean that the Medicare reimbursements for a large number of surgical procedures — orthopaedic, heart and other general surgery — will fall. The aim is to encourage modern clinical practices by shifting funding from lower-value to higher-value healthcare.

Doctors’ groups, private health insurance funds and private hospitals have called for the changes to be delayed to allow them time to adjust their internal processes and charging. The Australian Medical Association says that the changes, if rushed, could result in unexpected out-of-pocket costs for patients. Other industry and consumer groups, along with the Grattan Institute’s Stephen Duckett and UNSW’s John Dwyer, have supported the call for a delay.

Despite the lengthy process of expert deliberation leading up to the changes, Labor has called for them to be scrapped altogether, adding more confusion to an already complex issue.

The review of the schedule, which began in 2015, was a massive undertaking. Supported by a consumer panel and a public consultation process, a network of committees and working groups examined 5700 items listed on the schedule, producing more than sixty reports and 1400 recommendations.

As well as recommending changes to Medicare, the review proposed measures to increase the quality and safety of treatments, and to make access to medical services more equitable. The review of ophthalmology, for example, recommended increasing rebates in rural and remote areas to tackle current shortages. Some services that GPs are currently allowed to provide should, it recommended, be limited to specialists with the training that enables them to deliver a higher-quality result.

It’s hard to argue against recommendations like this that are based on evidence and developed collaboratively by clinicians, health economists and other experts, and consumers. And the sheer number of recommended changes highlights how overdue the review of the schedule was.

That shouldn’t be any surprise. Medicare was designed more than a generation ago, and since then our health needs have changed. Advances in medical and pharmaceutical research, and technological innovations have driven changes in clinical practice.

In some areas these have been dramatic. A procedure that once was time-consuming and demanded a high level of skill might now, with the assistance of technology, be performed much more quickly by a clinician with less training. Other services that were once common should no longer be performed because the alternatives are more effective and safer.

Implementing the changes may be complex, and arguments about the detail are inevitable, but the review was necessary and had wide support across the health sector. In fact, many Australians might be surprised to learn that this type of review doesn’t occur as a matter of course.

That’s why the controversy is more about the implementation than the changes themselves, though we’re also seeing the politicisation that inevitably accompanies any debate about Medicare.

Of course, the major professional groups can’t help protecting their own interests. The AMA, for example, is being disingenuous when it claims that concern about out-of-pocket costs is motivating its desire to delay the changes. It’s had plenty of time to act on this longstanding problem by doing more to tackle fee variations, particularly by reining in specialists who charge significantly above the recommended fees.

But the changes are administratively complex, and the short timeline does put unnecessary stress on hospitals, health funds and doctors. And it’s hard to see how delaying them for a few weeks or even months would cause any major problems; it would certainly buy the government some valuable goodwill across the sector.

Particularly at the moment, when the government is struggling with its own challenges in implementing the Covid-19 vaccine rollout, it should be sympathetic to organisations with fewer resources trying to grapple with changes to the Medicare schedule.

Labor’s blanket opposition — clearly motivated by the hope of a Mediscare-type campaign at the next election — isn’t helping. It may be understandable, but it’s a disappointing response from a party that should have a sophisticated understanding of the need to keep Medicare up to date. That’s not to say there’s no truth in Labor’s claims about the lack of underlying support for Medicare within Coalition ranks. But the Medicare schedule review is not the best target for trying to make this point.

Labor’s commitment to Medicare shouldn’t mean allowing it to ossify in the 1980s. If Medicare is to continue serving the needs of the Australian community, it needs to evolve. A sustainable and robust Medicare can’t continue to subsidise low-value care with outdated and non-evidence-based rebates.

What’s important at this point, though, is to make sure these administrative hiccups and attempts to politicise the review don’t derail longer-term improvements. So far the focus has been on changes to individual Medicare items, but the review also dealt with the need for system-wide reform.

A continuous review mechanism is needed, it said, to ensure that Medicare can evolve with changing clinical practices and community needs. The government and the AMA support that recommendation, but its success will depend on collaboration between the major interest groups. The government’s recent willingness to work with the AMA on implementing future review recommendations is a positive sign.

Also urgent is action on out-of-pocket costs, which make up 17 per cent of total health funding, or around double the contribution of private health insurance. Despite these costs’ impact on access and choice, the government shows little interest in how much consumers pay for medicines, health and medical services, and devices. Limited safety nets provide little protection for people with chronic, complex conditions who must pay a large number of relatively small amounts for medicines, supplements, dental services, allied health, medical gap payments, aids and appliances.

People who are charged unfairly by health professionals have little recourse, and the government’s half-hearted attempts to help them avoid these charges — via the medical costs website, for instance — don’t appear to have had any impact. Meanwhile, an entire branch of the health department deals with private health insurance, which is used by less than half the population and contributes only 9 per cent of health funding.

Medicare is a blunt instrument for tackling many of these issues. Changing rebates often has a limited impact, is complex to enforce and can result in perverse incentives. But Medicare is often the only tool the federal government has to drive changes and therefore should be used to its full potential. Allowing the sector some latitude in implementing the current changes would help create a climate in which longer-term improvements can be made. •

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

The post Labor’s mistaken Mediscare 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 case the court has agreed to hear, Jackson Women’s Health Organization v Dobbs, challenges the constitutionality of a 2018 Mississippi law that bans almost all abortions after fifteen weeks of pregnancy, with narrow exceptions for medical emergencies or foetal abnormalities. A federal district judge and a panel of the US Court of Appeals for the Fifth Circuit have both upheld an appeal against the law launched by the women’s health organisation that runs the only abortion clinic in Mississippi.

The case effectively reopens both Roe v Wade and the US Supreme Court’s 1992 decision in Planned Parenthood v Casey, which held that “the state’s interests” in relation to a foetus that isn’t yet viable “are not strong enough to support a prohibition of abortion or substantial obstacle to the woman’s effective right to elect the procedure.” In accepting the Mississippi case, the court says it will examine whether “all pre-viability prohibitions on elective abortions are unconstitutional.” The state’s attorney-general will argue that the capacity to survive outside the womb is the wrong place to draw the line.

Among developed nations, the longstanding and increasingly partisan political battle over women’s reproductive rights is uniquely American. Continual challenges to legal guarantees encapsulated in Roe v Wade and elsewhere not only undermine women’s freedoms but are also likely to be contributing to the appalling rates of maternal and infant mortality in the world’s richest nation.

A quick history lesson highlights how precarious the legal right to abortion is for American women. While Roe v Wade is commonly seen as guaranteeing a right to abortion, it secures only the right to privacy when seeking access to an abortion, thus protecting a woman’s autonomy in the decision to have an abortion.

Even this is mitigated by what the distinguished legal journalist Linda Greenhouse calls “a physician-centric framework.” To a remarkable degree, indeed, Roe v Wade is about doctors’ rights. The majority opinion, written by Justice Harry Blackmun, actually says that “the attending physician, in consultation with his [sic] patient, is free to determine, without regulation by the State, that, in his medical judgment, the patient’s pregnancy should be terminated.” This doctor-knows-best rhetoric could well have helped enable the limitations since placed on American women’s reproductive rights.

It is important to note that Roe v Wade is essentially superseded by the 1992 decision. When this case reached the US Supreme Court, only Justice Blackmun remained of Roe’s seven-member majority, and a majority of the justices had been appointed by presidents who openly sought its reversal. Even so, the court surprised everyone by reaffirming Roe’s central tenet of the right to an abortion; but it also instituted an “undue burden” standard that permitted the state to regulate abortion to protect unborn life from the beginning of pregnancy, so long as women’s authority to decide whether to give birth was protected. In taking this approach, the court created opportunities for restrictions on abortion that Roe itself never sanctioned.

In the wake of the Roe v Wade decision, anti- and pro-abortion groups were galvanised. At the same time, Republican strategists were staking out anti-abortion positions as part of a strategy to appeal to Catholic and evangelical voters. This was the beginning of a growing partisan divide on the issue, which has become almost a litmus test for aspiring Republican lawmakers.

Efforts to limit abortion soon turned to focusing on funding for reproductive services. The Hyde amendment, introduced in 1976 and enacted by every Congress since, bans the use of federal Medicaid funds for abortion services, with exceptions for pregnancies resulting from rape or incest and pregnancies that would endanger the mother’s life. It is particularly harmful to women of colour and those with low incomes, who disproportionately rely on Medicaid for their healthcare coverage. (Note that the Hyde amendment does not block states from using their own Medicaid funds; currently fifteen states pay for more abortions than those permitted under the amendment.)

Gallup polls report that around 50 per cent of Americans agree abortion should be legal “under certain circumstances” and another 29 per cent “under all circumstances.” This level of public support makes the federal political fight difficult, leading anti-abortion activists to be more relentless in their use of the courts and to target Republican-dominated state legislatures.

Donald Trump oversaw a major effort to curtail abortion. The “gag rule” was applied to recipients of US global health aid (a hard line that was particularly punitive for female victims of sexual violence during conflicts), access to contraception was restricted, and insurers and healthcare professionals were given more latitude to deny reproductive health services. He also made good on his promise to load up the Supreme Court with justices who would overturn Roe v Wade by appointing Neil Gorsuch, Brett Kavanaugh and Amy Coney Barrett.

Joe Biden has been reticent about speaking out on abortion. His election campaign didn’t highlight the issue, and he hasn’t taken it up since moving into the Oval Office. Perhaps his Catholicism has played a role, but more likely his silence reflects the many other important issues that need to be tackled.

But he has made a good start on rolling back Trump’s undermining of women’s health. He has reversed the restrictions on funding Planned Parenthood and overseas groups that provide abortion referrals; reversed restrictions on the supply of medical abortion drugs; and removed hurdles to medical research that uses foetal tissue derived from abortions. He has appointed vocal advocates of abortion rights to key federal posts, including Xavier Becerra as health and human services secretary.

The mere fact that the Supreme Court agreed to take up this case indicates it is likely to overturn or severely limit the judicial basis of abortion rights. None of the usual criteria for accepting a case were satisfied — there was no split in the circuit decisions and no unsettled question of federal law — and the case had languished on the court’s docket since before the death of Justice Ruth Ginsburg, an ardent support of Roe v Wade. Moreover, the newer, more conservative justices have already shown their willingness to overturn longstanding precedents and expand the scope of decisions.

Biden will be under enormous pressure to do more to protect abortion rights, not just because of fears about the outcome of Jackson Women’s Health Organization v Dobbs but also because of even more draconian state-level anti-abortion provisions. Sixteen states have attempted to ban abortion before viability, mostly with “heartbeat” bills, which seek to ban the procedure from the time a foetal heartbeat can first be heard. (This is six weeks from conception, at which time many women are still unaware they are pregnant.)

The anti-abortion legislation recently passed by the Texas legislature highlights what the future could look like without Roe v Wade (which originated in Texas). It not only bans abortions after six weeks but also allows private citizens the right to sue anyone who aids or abets an abortion — including healthcare workers and facilities, insurance companies, counsellors, families, the person who drives the patient to the clinic, and even those who donate funds to support abortion services. As lawyers opposing the legislation have argued, it enables anti-abortion groups to “weaponise the judicial system” to paralyse women’s healthcare services, isolate women who need abortions, and intimidate these women’s supportive networks.

All of these bills have been blocked by court orders, and await the undoing of constraints imposed by Roe v Wade. Many more bills are coming: since January, 549 abortion restrictions, including 165 abortion bans, have been introduced across forty-seven states; sixty-nine of these, including nine bans, have been enacted.

Biden made an election commitment to codify Roe v Wade into federal law and abolish the long-time ban on federal funding for abortions via the Hyde amendment. Vice-president Kamala Harris campaigned on a proposal to create a “preclearance” system, analogous to that in the Voting Rights Act, whereby states that want to change abortion access must seek approval from the justice department. In a first step, Biden’s fiscal 2022 budget request, just released, omits the Hyde language.

To enact any or all of these provisions, Biden must determine how much pressure he wants to put on the Democrats in Congress to tackle these fraught issues ahead of the 2022 elections. And there is an additional problem: all of these measures can only be passed if the Senate filibuster (a requirement for sixty votes rather than a simple majority) is abolished.

A more contentious way to tackle this issue — one that is already on the table for some Democrats —is to expand the number of justices on the Supreme Court (there is precedent, although not recent). A group of Democrats has introduced a bill to do this in the House of Representatives; and, not surprisingly, Republicans have been scathing in their opposition. But the bill has a doubtful future even without Republican opposition: House speaker Nancy Pelosi has said she has no plans to bring it up for a vote.

Although the court’s composition is clearly on Biden’s mind, he has been in no hurry to make a decision. In April he signed an executive order setting up a bipartisan commission to examine the court’s size, the justices’ lifetime appointments and other court-related matters, thus fulfilling a campaign commitment.

The key issue that may drive Biden and his administration to apply more effort to abortion rights specifically and women’s reproductive health more generally is his strong commitment to improving access to healthcare and creating a more equitable society. “We are deeply committed to making sure everyone has access to care — including reproductive health care — regardless of income, race, zip code, health insurance status, or immigration status,” Biden said in a joint statement with Harris on the forty-eighth anniversary of Roe v Wade in January.

The hard line against abortion rights that is so prevalent in American politics puts women’s lives, livelihoods and health at risk and widens the disparities between rich and poor that are already a feature of US healthcare. More importantly, the current battles ignore the real-life complexity — ethical and financial — of ending a pregnancy. That is not likely to change any time soon. •

The post Roe v Wade v Trump appeared first on Inside Story.

Despite its flaws, and despite a decade of attacks by congressional Republicans, the ACA — or Obamacare, as it is often called — is more popular than ever. A February poll showed support at 54 per cent, with many of those saying they oppose Obamacare supporting its provisions when they are spelt out. But that popularity seems only to have hardened Republicans’ resolve to fight its expansion.

On his first day in office Biden use presidential authority to rescind an array of healthcare-related executive orders made by his predecessor and implement his own policies. He appointed a new Covid-19 response coordination team. He withdrew Donald Trump’s Medicaid waiver, which allowed states to restrict eligibility using work requirements. He rolled back restrictions on reproductive health and the use of foetal tissue n research. He revived US membership of the World Health Organization and the Paris climate accord.

Biden also restored science and scientific expertise’s central role in health-related policymaking, reinstated workplace and environmental protections, and reversing the Trump administration’s hostile stance on gay rights and racial justice — all decisions just as important for Americans’ health as expanded health insurance coverage and improved access to healthcare services. (Kaiser Health News keeps a list, aptly titled The Great Undoing, of his ongoing efforts to undo Trump’s health policies.)

But the real work of restoring and expanding Obamacare involves writing the detailed legislation that must then pass Congress. With a Democratic majority of only six votes in the House of Representatives and just one (the vice-president’s) in the Senate, and with little or no chance of Republican support, that will be an enormous challenge.

Biden signalled where he was heading early. The US$1.9 trillion American Rescue Plan Act, the first of three bills that make up the Build Back Better plan, was made public before he took the oath of office. It focuses on pandemic relief, rescuing the American economy, opening schools, scaling up vaccination, and in other ways controlling the pandemic.

Aside from one-off payments to all Americans and increases in tax credits — measures that will temporarily lift many children out of poverty — short-term funding was also provided to lower the cost of health insurance premiums and pay the private health insurance of laid-off workers. Unemployment, nutritional assistance, rental and mortgage assistance benefits were boosted; Native American communities received US$8.3 billion for health, housing and education programs; and new financial incentives were introduced to encourage the twelve remaining states (led by Republicans, mainly southern and poor) to take up Obamacare’s expansion of Medicaid.

Biden’s time in the Obama administration had brought home to him the hazards of endless and ultimately fruitless negotiations with Republicans. He knew that bill must be passed in full, and quickly.

The American Rescue Plan Act was signed into law on 11 March, having passed through Congress without attracting a single Republican vote. As a result, Biden could mark his first hundred days in office with most Americans having received their promised relief payments, some 200 million Covid-19 vaccinations having been carried, out and many other achievements. The economy is roaring back, if unevenly, and the White House is characterised by action, transparency and an air of normality. Polling shows Americans are the most optimistic they’ve been about the nation’s direction in nearly fifteen years.

This gives the president the political capital to proceed with the two other parts of his Build Back Better agenda — US$2.3 trillion over the next eight years for the American Jobs Plan and $1.8 trillion for the American Families Plan — both of which include health and healthcare provisions.

Although the American Jobs Plan is primarily about rebuilding America’s rundown infrastructure, investing in green energy and creating jobs, it will also provide funding for the social supports that advance equity and aid access to healthcare. These include investments in broadband access, public transport, affordable housing and safe drinking water, all of which will especially benefit low-income and minority communities.

One of the package’s ground-breaking initiatives is the US$400 billion allocated to expand and upgrade community-based care for the elderly and people with disabilities, and an almost doubling of current spending under Medicaid. Although these funds seem unlikely to meet demand — especially given fears about the safety of residential care in the wake of Covid-19’s toll — they could dramatically improve the lives of those in home care and their carers. The latter are mainly immigrant women, often living below the poverty line without health insurance, whose median hourly wage is only US$12.60. During his election campaign, Biden spoke out about the need for this important part of the healthcare workforce to be given pay raises, workplace protections, paid family and medical leave, job training programs and collective bargaining rights.

The third component of Build Back Better, the American Families Plan, covers education, childcare, paid family leave and healthcare. It expands the American Rescue Plan’s premium tax credits for health insurance and provides US$2 billion to train skilled healthcare workers. It also tackles the social determinants of health by providing free meals to children in areas of high poverty and creating a healthy foods incentive program.

Education is directly linked to self-rated health, infant mortality, life expectancy and compliance with medical advice. Programs that close gaps in educational outcomes between low-income or racial and ethnic minority populations and higher-income or majority populations are essential to achieving health equity.

Congressional Republicans are predictably outraged by these US$6 trillion spending plans. They have accused Biden of pursuing a radical agenda that will turn the United States into a failed socialist state, and reject even job creation and infrastructure initiatives they (and Trump) once supported. They don’t see broadband or the removal of lead pipes carrying drinking water as infrastructure, and they claim that home care services were “shoehorned” into the plan.

Senate minority leader Mitch McConnell declared that the Biden administration “wants to jack up taxes in order to nudge families toward the kinds of jobs Democrats want them to have, in the kinds of industries Democrats want to exist, with the kinds of cars Democrats want them to drive, using the kinds of childcare arrangements that Democrats want them to pursue.”

Just as anathema to the Republicans are the increases in corporate taxes and taxes on individuals earning more than US$400,000 needed to pay for these bills, measures designed to avoid boosting an already huge federal deficit. Unsurprisingly, the Republicans’ appetite for remaking the economy is small, as evidenced by their US$568 billion infrastructure counter-proposal, which deals narrowly with roads, bridges and other transport infrastructure and ignores the economic possibilities of green jobs and clean energy.

Biden recognises that he has a unique opportunity to make what he has called a “once in a generation series of federal investments in our nation’s future.” With the pandemic having highlighted the consequences of relying on the market to deliver affordable and accessible services, a majority of Americans now supports a single-payer health insurance system and 69 per cent favour a public option that would compete with private health insurance.

Recognition is also growing that the much-touted American exceptionalism involves lower life expectancy, higher suicide rates and higher rates of avoidable deaths than in comparable countries. Many Americans now see the consequences of what happens when healthcare is neither universal nor affordable and paid family leave isn’t guaranteed.

Joe Biden is acutely aware of the Democrats’ narrow majorities in the current House and Senate and the distinct possibility these could be overturned in the next election cycle. His response is to go big, go fast and go partisan to get his plans in place before the 2022 elections.

The president has found considerable bipartisan support for his proposals in the community. Indeed, his ideas are often more popular than he is (his approval rating is currently around 54 per cent) and in most polls that support also comes from many Republicans. An ABC News/Washington Post poll conducted on 18–21 April found that 65 per cent of Americans support the now-enacted coronavirus relief package. Several different polls indicate that a majority of voters want Congress to pass the American Jobs Plan, and the more people know about it the more they approve. Polling also shows strong approval of the care-giving provisions, with a Morning Consult/Politico poll showing 76 per cent support (including 64 per cent among Republican voters). A Monmouth poll shows widespread enthusiasm for the American Families Plan, with 64 per cent support and 34 per cent opposition.

Nor are American voters particularly fazed by the price tag, or the increased taxes needed to pay it. A CBS News/YouGov poll, for example, found that Americans support raising taxes — on individuals earning more than US$400,000 a year and on corporations — by the same wide margin of 71 per cent to 29 per cent. A Monmouth poll found support for higher corporate taxes at 64 per cent and for raising taxes on those earning more than US$400,000 at 65 per cent. Some Republican lawmakers have even been touting the benefits Biden’s Covid-19 relief plan has delivered to their districts.

The president’s problems with Congress are not confined to managing the Republicans; there is obstinacy and dissent among the Democrats, especially those on the left who want more, and want it quicker. Biden campaigned on giving Americans universal healthcare coverage, and that is still a long way off. Estimates put the percentage of uninsured Americans at 12.5 (rising to an average of 15.5 per cent in states that have not expanded Medicaid): that’s twenty-nine million people, mostly low-income and people of colour, with another 21.3 per cent under-insured.

To reduce those figures significantly, two things need to happen: the cost of health insurance purchased privately and through the Obamacare exchanges needs to fall, and the recalcitrant states need to expand Medicaid. Biden is already tackling these issues, but more needs to be done. The new supplements for purchasing health insurance run for only for two years, and twelve states (with some four million eligible people) have yet to expand Medicaid.

In the absence of universal healthcare, Medicaid is an important, if shaky and uncertain, safety net. It provides mental health and substance abuse treatment for millions and covers almost half of all births. The states holding out against expansion are losing money they can ill afford, especially as coronavirus infections continue. Just last month, the Texas State House rejected Medicaid expansion because of continuing opposition from Republicans. Expansion would have enabled some 954,000 adults to receive healthcare coverage (about 75 per cent of whom are people of colour) and brought the state US$5.4 billion in federal dollars to pay for it.

Rather than funding expanded health insurance coverage through private insurers, progressive Democrats and some policy experts argue for a public option (as originally proposed in Obamacare) and/or for people aged fifty-five or sixty qualify for Medicare (an idea that was championed by Hillary Clinton in her 2016 presidential race).

Congressional Democrats led by Senator Bernie Sanders and the Congressional Progressive Caucus are pushing to have Medicare expansion included in the American Families Plan. They see this as a precursor to an eventual Medicare-for-All program. A broader group of Democrats is pushing for the American Families Plan to allow Medicare to negotiate prescription drug prices. Biden has endorsed these, and the public option, in the past.

In his speech to the Congress Biden promised that he would strive “this year” to lower insurance premiums, reduce drug costs and pursue other reforms to Obamacare. Presumably he feels that including these provisions in the American Families Plan would draw fire from the powerful health insurance, hospital and pharmaceutical corporations, making its passage through Congress even more difficult.

Sometime between now and 1 October the administration and Democrats must also confront the decision of the US Supreme Court in the California v Texas, a case brought by Republican state attorneys- general and supported by the Trump administration. The decision will essentially decide the fate of Obamacare and the survival of the entire Affordable Care Act. Analysis shows that it would adversely affect the lives of almost all Americans.

Should the worst happen, re-enacting a version of the Affordable Care Act in today’s political climate would be almost impossible, even as more Americans than ever are signing up for the health insurance coverage provided by the federal Obamacare exchange. It would be a dreadful irony if Trump’s legacy, delivered after he left office, was — finally — the end of Obamacare.

For this reason alone, but for so many others besides, Biden’s efforts to provide the United States with the kinds of government services that other wealthy, democracies already take for granted and to build voter support for a stronger social safety net are a national imperative. •

The post Building Obamacare back better appeared first on Inside Story.

It is a small but historic moment. And a strange one. Psilocybin and the fungi from which the compound is derived have been used in shamanic and other Indigenous rituals for centuries. The mushrooms are said to be depicted in artworks thousands of years old. They have been consumed by hippies in the Summer of Love, decried by former US president Richard Nixon and eventually outlawed. They have even informed their own theory of human evolution (US ethnobotanist Terence McKenna’s ‘Stoned Ape Theory’). But today they are being harnessed by Western medicine to try to ease the terror of dying.

The figure on the day bed is the first of about thirty-five desperately ill patients who, with the help of Ross and her team, will each take a legal psilocybin trip (sometimes two) as part of the nation’s first approved randomised controlled trial of psychedelic psychotherapy. In fact, only two patients will go through the treatment early in 2020. And then suddenly it will all stop. Four days later, Ross will be back on the ward, in scrubs, counselling traumatised staff about how to care for patients, families and themselves as Melbourne enters its first lockdown. But what she sees in those extraordinary days before the trial is suspended will change the way she thinks about her work, her patients and the possibilities for treating some of the country’s saddest and sickest people.

So, definitions. Psychedelic therapy (psychedelic: from the Greek roots of “mind” and “manifesting’) first emerged as a subject of clinical research in the US in the late 1940s, with the release of the mind-altering, era-defining hallucinogen lysergic acid diethylamide, or LSD. During the 1950s and ’60s, tens of thousands of people took LSD — marketed initially as a cure for mental disorders from schizophrenia to “sexual perversion” — as part of the first wave of psychedelic research, before the drug, and psychedelics generally, fell victim to the social and political upheaval of the times. These days researchers prefer to focus on psilocybin — which is less potent than LSD and less stigmatised — as well as MDMA (“ecstasy”), which while not technically a psychedelic does some similar things to the mind, seemingly by lowering defences and promoting new ways of thinking. Researchers also prefer to talk about “psychedelic [or psychedelic-assisted] psychotherapy,” to emphasise that the drug treatment is securely corralled in a series of counselling sessions.

For those who give the topic any thought (I get mainly blank looks when I raise the subject with medical acquaintances), attitudes towards psychedelic psychotherapy range from dismissive to evangelical. In one iteration it is an undercooked, overhyped, potentially dangerous fringe treatment that could divert desperately needed funding from other areas of the already stretched mental health budget. In another, it is a paradigm-shifting therapeutic frontier that could reconfigure Australia’s treatment of hitherto intractable mental conditions — such as deep, persistent depression and post-traumatic stress — within a decade and also transform our approaches to other illnesses, including addiction, anorexia and obsessive-compulsive disorder.

There is another option that gets less airplay, but that is worrying psychedelic researchers here and worldwide. More on that later.

For now, and after a slow start — “We are very conservative in the research area; we’re a very conservative country,” says one researcher — Australia is turning towards psychedelic drugs to help treat some of our most entrenched and distressing mental illnesses. In November 2020, researchers at Melbourne’s Monash University announced the university would sponsor two new trials: one a large, world-first study of psilocybin to treat crippling anxiety; the other exploring the role of MDMA in treating severe post-traumatic stress disorder, or PTSD.

Several smaller trials are also ready to go, including a partnership between Melbourne’s Swinburne University and St Vincent’s Hospital that will study the impact of psilocybin-assisted psychotherapy on treatment-resistant depression; another on the role of MDMA in treating PTSD from Perth’s Edith Cowan University; and one from St Vincent’s Hospital Sydney on methamphetamine addiction. Other psychedelics of interest include the South American brew ayahuasca and its potent active ingredient, DMT.

Those involved in the trials hope they will lay the groundwork for psychedelic psychotherapy to one day become an approved, Medicare-funded treatment for thousands, maybe tens of thousands, of Australians whose mental conditions are resistant to conventional treatments, and whose daily lives span a continuum from distressing to unendurable.

But they warn that getting there will be difficult. Nor is it guaranteed. Along with the usual logistical and regulatory juggling over the approval of any new drug are personal, professional and political faultlines that must be navigated if Australia is to achieve a workable model of psychedelic psychotherapy (even now the temptation is to overlay the words in retro colourways). And before and beyond all that is the sheer mind-bending otherness of the experience at the heart of the proposed new therapy — an experience only partially amenable to language, which scientists in respected journals describe as “ineffable,” “mystical” and “transcendent,” and one that is embedded in a process that can involve a profound reckoning with the self and its place in the world.

“The psychedelic experience can open people up to long suppressed feelings both negative and positive,” says a 2020 paper from Rosalind Watts of London’s Imperial College. “It can involve peak experiences, mystical states, and experiences of intense, all-encompassing love and bliss.”

And from this flow great possibilities and great challenges.

In a noisy outdoor cafe opposite the hospital, Margaret Ross is searching for words. “There’s times when I have to really sit and percolate on an idea and kind of really, really feel it in my bones before I give a thoughtful answer.” She listens attentively, laughs frequently, talks in flurries. But she knows that talk only gets you so far.

Ross has spent much of her life among the dying. At seven, she was deeply affected by the death of a beloved grandmother. As a clinical psychologist working with palliative care patients, many from the St Vincent’s cancer wards, she has spent years thinking about how best to help people who can no longer be helped — at least not in the way that most of us entering a hospital want to be helped. She has researched the psychological impact of cancer and other terminal diagnoses. She has seen some remarkable deaths.

And she has seen a lot of fear. The publicity material for the Melbourne trial describes the “depression” and “anxiety” of some terminal care patients — words that seem barely to touch the sides of what Ross encounters in her work. First, she says, is the fear of death itself, the “annihilation of self.” Cascading from this central void is grief at leaving behind a partner, a sister, a child (“especially children”) and fear for their welfare in a world where you will no longer be there to love or protect them. Then there is the physical and mental dismantling that is the dying process (“Will there be pain, indignity, will I lose control?”). And fears about the relentless, incremental losses that define a terminal diagnosis: identity, independence, relevance, control. Even as a therapist, says Ross, it is hard sometimes not to feel helpless. “I see so much terror and distress.”

“We set up a kind of little camp”: Clinical psychologist Margaret Ross and her colleague, psychiatrist Justin Dwyer. Kristoffer Paulsen/Nine

When Ross was sixteen, her mother was diagnosed with a serious respiratory disease. She fought it for a long time and died when Ross, the youngest of five sisters, was twenty-seven. “She never really made peace with it. She loved life too much. She didn’t want to leave her girls… And she was absolutely terrified of death. So I’ve had an interest in death, the way people square with it, for a very long time.”

As a young psychologist, says Ross, she started thinking about the therapeutic potential of altered states such as meditation and yoga. She trained in hypnotherapy. Anything that might help people find a way through. When a new wave of international research into the therapeutic potential of psychedelics started emerging in the early 2000s, she paid attention. More so when, in 2016, two key studies came out of the US on the impact of psilocybin-assisted psychotherapy on the mood and attitudes of patients with life-threatening cancer. The results, she says, were “staggering.” The trials, one from New York University and the other from Johns Hopkins University in Baltimore, found rapid, sizeable reductions in depression and anxiety that for many would go on to last six months or more.

It was what Ross had been looking for. A way in.

Like most of those I have met in researching this article, Paul Liknaitzky confounds lingering stereotypes of the “turn on, tune in, drop out” variety. Neat, articulate and with a sentence structure girdered in careful clauses and subclauses, he could be a rising public servant. He is also determined. As a teenager he navigated solo through a series of distressing psychological episodes — “spontaneous and terrifying altered states of consciousness,” he calls them — eventually breaking the cycle by standing in front of a mirror, staring into his own eyes (“If I die, I die”). Which may help explain his centrality in the emerging framework of an Australian psychedelic therapy.

Margaret Ross describes him as the “mycelial network” of Australia’s psychedelic research world, referring to the underground web of microscopic fungal fibres that link and sustain diverse communities of plants. A research fellow at Monash University, he is co-ordinator of the St Vincent’s trial, and chief principal investigator on the upcoming Monash trials as well as several others now taking shape in the fertile loam of Australia’s nascent psychedelic research landscape.

The possibilities, he says, are astonishing. “There is uncharted territory wherever I look.”

Admittedly, any discussion of the potential benefits of psychedelic drugs in treating mental illness takes as its baseline the shortcomings of existing pharmacological models. The 2020 Productivity Commission Inquiry Report into Mental Health estimates the economic costs of mental illness and suicide at up to $70 billion per year in Australia, plus another $150 billion or so in reduced health and life expectancy. The most common drug treatment for depression, selective serotonin reuptake inhibitors, has been shown to help only about half of patients, with high relapse rates after discontinuing and no major breakthroughs in more than thirty years.

“That indicates to me that we have some fundamental assumptions about mental illness that are wrong,” says Liknaitzky.

Even measured against that relatively low base, the early indications for the potential of psychedelics — across a wide and growing range of mental disorders — has been galvanising.

In the past two decades, studies have shown significant, sometimes startling, improvements in conditions including death anxiety, treatment-resistant depression and PTSD. In recent years, high-profile psychedelic research centres have opened in major universities, including Imperial College and Johns Hopkins, as well as in Basel and Zurich. The US Food and Drug Administration has designated MDMA therapy for PTSD, and psilocybin therapy for depression as “breakthrough therapies.” One recent study using psilocybin to help treat long-term depression reported an effect around four times that of traditional antidepressants.

One of the primary claims made by researchers in the field is that unlike drugs such as antidepressants, psychedelics are not treating symptoms but root causes often related to childhood or other trauma. While it may be decades (or longer) before we truly understand the brain mechanisms by which psychedelics exert their disorienting effects, recent research suggests that psilocybin quietens a brain region called the default mode network, which includes the circuitry involved in how we remember our lives, and the stories we tell ourselves about who we are. In classic psychoanalytic terms, it seems to dial down the ego, lowering our psychological defences, helping us to think in more open and flexible ways, and increasing our sense of connection to ourselves and others.

“The opportunity there is for patients to consolidate aspects of themselves or their lives that have been repressed,” says Liknaitzky, “to gain new and helpful perspectives on old problems, and to feel, emotionally, a much stronger alignment with their values and what’s important in life — and to be motivated to act in accordance with [those] values.”

Of course, these sorts of insights, the ability to access and recast buried thoughts, memories and feelings and to change our behaviour accordingly, are the goal of much psychotherapy, as well as a benefit of some meditative practices. But psychedelics seem to turbocharge that process. And unlike some of the hard-won insights that arise through talk therapy, Liknaitzky suspects that the fundamental alteration psychedelics bring about is not a thought or idea, but “an embodied encounter or a revelation.” And that this suggests a greater possibility of long-term change, at least for some.

I speak with “Clare,” a social worker who tried psilocybin last year in a bid to overcome a debilitating, corrosive lack of confidence — she calls it “imposter syndrome” — that was affecting her personal life and interfering with her work. She took the drug illegally, though with the support of a trained therapist with an interest in psychedelic medicine and, she says, a lot of preparation. She describes a series of discrete scenes, each like a small film: an emotional encounter with her estranged mother; a vision of her seven-year-old self; a meeting with a large benign rat; and finally, herself, in a room, surrounded by family and friends, able in this moment to see herself through their eyes. “And it was just — it was full of love. And I felt like my heart was gonna burst with love and pride. For myself.” She says the experience has changed her understanding of childhood trauma and taught her what “self-care” really means — changes that have flowed into all aspects of her life. “It was one [of]…if not the most significant experience in my life.”

“People report a verisimilitude,” says Liknaitzky, “which is that your representation of reality seems to be more reliable than your sober one. And that’s a striking experience. It’s as though you’ve woken up from the dream of your life.”

Admittedly, he says, for the most part the insights that come out of the psychedelic experience sound like platitudes. “I mean you can pop them on a Hallmark card. You know, ‘love is all there is.’ Actually, what matters is that if you can genuinely feel that love is all that matters, then that is absolutely profound. And you can’t talk yourself into feeling that. You can’t talk yourself easily into feeling compassion for an abusive mother, for example, but once you’ve actually had that encounter, then you’ve got a possibility of having quite a different relationship to whatever was disturbing you.”

The trial takes place in the retreat room at St Vincent’s Cancer Centre, fitted out with the daybed, warm furnishings and, on dosing days, pot plants and an Indigenous painting that Ross brings from home. “It’s a lovely space.” The study follows the design and protocols of those two key US studies from 2016.

In the lead-up to this day, Ross and psychiatrist Dwyer, who is co-principal director on the trial, have interviewed eight patients, eager — some desperate — to participate, assessing their physical and mental suitability, as well as excluding anyone with a history of psychosis, bipolar disorder or some types of complex trauma — all of which can be aggravated by psychedelics. Many don’t make it through this initial screening. Others do, but later deteriorate. Some die. “Things can happen, and they have happened,” says Ross. “People can be devastated.”

Crucial to the emerging treatment are the so-called ‘set and setting’ protocols identified in the first wave of modern psychedelic research and refined in the past two decades: the mindset and intentions you bring to the experience, and the setting in which it takes place. One of the striking features of psilocybin is that its benefits are related to the nature of the experience you have while taking it. Feelings of awe and transcendence have both been linked to improved outcomes in trial participants. At the same time, the experience is powerfully contingent on the environment and atmosphere within which people take the drug, the preparation they have had leading up to taking it, and their relationship with the therapists who will be supporting them before, during and as part of the crucial consolidation period afterwards.

The difference between a “bad trip” and a challenging but rewarding trip is mainly preparation and consolidation, says Ross. She recently came across an analogy she likes: “It’s the psilocybin experience that kicks the doors open. What you do with it after that is up to you.”

On the day of the drug treatment, she says, the therapist’s role is largely hands-off. She and Dwyer will sit with their charge and pay close attention to their emotional and other reactions; they will help or comfort if needed, but generally won’t intervene unless invited (a reassuring word, a glass of water, a hand to hold.) The music seeps into the room as well as the patient’s headphones, providing an intense, evocative soundtrack. “I can’t articulate how much more raw and stripped back you feel as a therapist.”

Patients arrive at 8.15 am. They are invited to bring with them personal items of significance, talismans that might help them feel safe or remind them of what is important to them. “We set up a kind of little camp,” says Ross, “because we’re there for hours.” Dwyer checks their blood pressure and heart rate, which will be monitored throughout the session. (While psilocybin so far appears reassuringly safe overall, physical side effects can include raised blood pressure, nausea or headaches, although these are generally short-lived.) They chat. Patients revisit their intentions for the trip, what they hope to explore. And Ross might remind them of the poem they talk about during the sessions leading up to “dosing day’: “The Guest House” by Persian poet and mystic Rumi:

This being human is a guest house.
Every morning a new arrival.
A joy, a depression, a meanness…
Welcome and entertain them all!

Central to the emerging model of psychedelic therapy is a confronting and not very fashionable idea: this treatment may at times be difficult; it may be painful; you may be afraid.

From a gently swaying houseboat on London’s River Thames, Rosalind Watts talks about “moving into the darkness.” One of the rising stars of the UK’s psychedelic research sphere, Watts has thought a lot about how to prepare therapists and patients for a paradigm based on the acceptance of psychological pain in a culture that routinely prioritises numbing.

“It’s like seasons,” she says “It’s darkness and light. And in our culture, it’s very much about — it should always be summer, you know, everyone should be happy, we should be busy, we should be productive, avoid the darkness… keep it light.”

But it is in accepting the darkness, she says, that her patients have a chance to heal.

She understands that some will simply not want to undertake a disorienting, sometimes gruelling, interior journey during which, even under ideal clinical conditions, nearly a third of volunteers can experience “significant fear,” albeit transient, according to a recent US study. “It won’t be for everyone.”

But for those who do, she says, the results can be transformative.

Until recently, Watts was a clinical psychologist at Imperial College, leading a major study comparing the impacts on depression of psilocybin versus a conventional antidepressant. Those results had not been published before this article went to print. But a smaller feasibility study reported striking reductions in treatment-resistant depression and later helped inform Watts’s development of a framework to help therapists prepare patients for the psychedelic journey. (‘Without a framework a psychedelic experience can be kind of like a nebulous dream.”) Her “Accept, Connect, Embody” model encourages patients to visualise diving into the ocean to the seabed to find oysters containing hard and difficult things.

Back in Melbourne, the St Vincent’s team use different metaphors, though with the same aim (Margaret Ross is a fan of Watts’s work). While the decision is always for the patient to make, says Ross, her counsel — as they prepare to enter the unknown — is to invite in whatever they most want to turn away. And to surrender.

“You might experience bliss,” she says, “you might experience oneness with the universe. You may feel your body like it’s dissolving or warping. Or, you know, it might feel quite scary. Don’t worry, your heart is still going to beat, your lungs are still going to breathe. It may feel like you’re dying, you may feel like you’re going crazy, and it’s okay.”

But outside the small, still room in Fitzroy, pressures are building.

In December 2020, an online opinion piece in the prestigious Journal of the American Medical Association Psychiatry issued an unambiguous warning about the future of psychedelic research. Despite — indeed because of — the promising results of recent clinical trials and the “seemingly exceptional potential” of the treatments, the so-called renaissance in psychedelic research was at risk of being derailed. The same sorts of “exuberance, utopian thinking, and uneven clinical approaches” that had led to the banning of these substances in the 1960s, “combined with the contemporary tendency to politicise science,” could do the same again, depriving potentially millions of people of future treatments.

The authors — one of them the world-leading researcher and founder of the Johns Hopkins Center For Psychedelic & Consciousness Research, Roland Griffiths — called for more studies into the drugs’ mechanisms and risks, as well as into how best to administer them in hospitals or other clinical settings. Psychedelics, they warned, were neither a quick fix nor a panacea.

Most of all, they called for restraint.

A similar conversation is now happening in Australia. “Understandably, there’s a lot of pressure to get the treatment out there as quickly as possible,” says Melbourne psychiatrist Nigel Strauss. “But really, we’re not ready for that yet.”

A prominent trauma therapist, Strauss has worked  with survivors  of Tasmania’s Port Arthur massacre and Victoria’s 2009 Black Saturday bushfires. He also has a longstanding interest in the therapeutic potential of psychedelics. Now in his seventies, he travelled to the UK in 2014 to do the MDMA therapy training program run by the pioneering Multidisciplinary Association for Psychedelic Studies. Last year, MAPS released follow-up results of phase 2 clinical trials of MDMA-assisted psychotherapy for PTSD showing that 56 per cent of participants no longer met the criteria for the disorder two months after treatment, with two-thirds of those still clear after a year or more. Phase 3 trials are now underway, amid building hopes that the drug might be approved for medical use in the US this year.

Strauss has personally funded most of the pending Monash PTSD study and is set to head the upcoming Melbourne trial of psilocybin for intractable depression. But he too urges restraint. “The last thing we want is for mistakes to happen.” Last year he set up a group of like-minded psychiatrists, Australia New Zealand Psychiatrists for Psychedelic-Assisted Psychotherapy, to discuss and prepare for the possibilities and challenges ahead.

There is no shortage of challenges.

Some relate to gaps in the knowledge. How does it work, for instance? How to more accurately gauge who is or isn’t a suitable candidate for psychedelic therapy? Why do some people have life-changing experiences while others don’t respond at all? How to minimise the risk of retraumatising already vulnerable patients?

Some are to do with questions of access and equity: how to ensure that those most in need will get to use the treatments — not just the wealthy, white and connected?

Other questions arise from the curious nature of the relationship between the drug, the person taking it and the therapeutic framework within which it is taken. There are harrowing accounts of patients emerging from deep and chronic depressions after psilocybin treatment, only to relapse months later. Paul Liknaitzky wants to know more about dosing regimens — how often, how much? — and is also keen to explore ways of prolonging the benefits of the “psychedelic encounter” by combining it with other mind-altering practices. “It’s not a drug you can take home. It’s a drug that needs a lot of support,” he says.

This puts particular demands on the therapists who might someday administer these therapies.

It is also one source of a growing rift between sections of Australia’s psychedelic research community and the high-profile, Melbourne-based advocacy and education group Mind Medicine Australia, or MMA. Launched as a charity in 2019 by philanthropist and opera singer Tania de Jong and her investment banker husband Peter Hunt, MMA promotes the use of medically controlled psychedelic-assisted treatments with a focus on psilocybin and MDMA to help counter the rising toll of mental illness. The couple founded the organisation following their own transformative psilocybin experiences (they travelled to the Netherlands, where they could legally take the drugs with a private therapist), and subsequently provided some early funding to Margaret Ross’s study via the charity Psychedelic Research in Science & Medicine.

Recent MMA projects include seeking to reschedule psilocybin and MDMA from prohibited substances to controlled drugs under the Poisons Standard — a move that could also make it easier for doctors to seek special access to the drugs for individual patients under a scheme already in use for medicinal cannabis. The MMA website has published moving extracts from dozens of submissions from patients and mental health professionals supporting the change — including one from de Jong herself, who is the daughter of Holocaust survivors. But critics in the psychedelic research community (even some who don’t believe the drugs should have been scheduled in the first place) argue that efforts to expedite the therapy are premature and potentially risky. In February, the Therapeutic Goods Administration delivered interim decisions acknowledging “significant public support” for rescheduling both substances but opposing the moves at this stage, citing “the risks to consumers, the lack of training for physicians, and the current state of research.” A final decision was due in late April.

Meanwhile, MMA is this year rolling out its own Certificate in Psychedelic-Assisted Therapies. According to its website, the $7,500 four-month course — available to experienced mental health practitioners, including social workers and occupational therapists — will take in components from overseas courses, input from local and international trainers and experts, and workshops, one of which will offer participants experience with breathing techniques designed to induce altered states. However, trainees cannot currently legally use or work with psychedelic substances, or administer them to patients.

Nigel Strauss and Paul Liknaitzky contend that, at least initially, all training should take place within clinical trials overseen by experienced international clinicians and be limited to psychiatrists, psychologists and psychotherapists. Liknaitzky has been developing a program to provide on-the-job training initially for around thirty therapists who will work on the Swinburne and Monash trials and who, he says, will later be able to train others. “These trials are an opportunity to train therapists ethically and rigorously through expert supervision, with real patients, using these drugs.”

Five of those I interviewed for this piece, including Liknaitzky, Strauss and PRISM’s Martin Williams, have quit MMA positions in the past eighteen months. Among the latest to go is British psychologist Renee Harvey, a highly qualified clinician who has worked on psychedelic trials at Imperial College, and who MMA hired to set up and run their training program. Harvey would not discuss her time at MMA or her sudden departure, except to say that she was happy for it to be known that she had resigned.

The broader arguments are at times confusing and/or personal, but seem largely to boil down to disagreements over the pace and process of change.

“More research on psychedelics would be brilliant,” says MMA’s Peter Hunt. “But the question that we all have to face up to is, when do you actually allow these medicines to be used for people that are suffering? In other words, when is the evidence sufficiently good to warrant any residual risk you’re taking by using these medicines with patients?” Given proper screening, support and medical controls, he says the time is about now. He points out too that antidepressants carry their own risks.

The outgoing head  of  psychiatry  at  Melbourne  University  and  St Vincent’s Health, Professor David Castle, has his own concerns. Speaking generally, he says: “The worry, I suppose, with the field is that some people have sort of leapt ahead of the evidence… And actually, you know, if you look at the scientific evidence, it’s relatively light on. It’s hugely exciting, but in terms of an evidence base, it’s very small.” Castle, who is leaving Australia to take up a position at Toronto’s Centre for Addiction and Mental Health, is a former board member of MMA. He hopes to pursue his interest in psychedelic research in Canada.

There is fear on both sides. On the one, that research and approvals will come too late for people who are barely hanging on. On the other, that without a rigorous, transparent scientific process that focuses on the local landscape as well as connecting Australia to the international research effort, the risk of mistakes rises, and with it the spectre of the research once more going off the rails.

John Allan, president of the Royal Australian and New Zealand College of Psychiatrists, is a cautious voice. Despite some promising results, he says, the research is in its early stages. “There is a history of controversies involving supposedly game-changing psychiatric treatments that, despite best intentions, have been based more in enthusiasm and hope than in rigorous research, and have ended up doing harm to people and to the future of psychiatric treatments.” He says the college is open to new treatments that improve lives, and that Australia’s research is of high quality. “But we just have to be really careful. And we have to do the science properly.”

There are bigger questions too — that go to the heart, perhaps the soul, of the psychedelic experience. But these are questions for later.

Ona mild, sunny Melbourne day in January 2021, ten months after the historic psilocybin trial was suspended, Marg Ross is back at her desk in St Vincent’s Hospital. In front of her is a list of names of patients who had originally expressed interest in the trial. “Inevitably we will have lost some,” she says. But today she will start making calls.

It will be another three or four years before the trial is completed, and at least a year before interim results are available. And even then, she says, she will need to protect the privacy of her patients. There is a lot she can’t say.

However, reports from patients from the 2016 New York University study give a sense of the range and intensity of their experiences. A subsequent qualitative study describes participants’ “exalted feelings of joy, bliss, and love; embodiment; ineffability; alterations to identity; a movement from feelings of separateness to interconnectedness; experiences of transient psychological distress; the appearance of loved ones as guiding spirits…”

“I feel like a whole bunch of crap has been dumped off the surface,” said one woman, who until her psychedelic experience had been just watching “the clock numbers ticking by.” Now, she said, “ just watching that tree over there blowing in the breeze, seeing people in the street, and all the different people in vehicles rushing by! I just feel good about being alive.”

What Ross can say is that the experience of sitting with her two first patients was profound — she uses the word repeatedly, apologising for doing so. She uses the words “extraordinary” and “stunning” too. She talks about learning to trust the deep inner wisdom — the “genius” — of the patient. She says that more than once the experience brought tears to her eyes. That seven weeks after one of those early sessions, she came across a researcher who had just done a follow-up interview and was now weeping in the corridor.

“I said “Are you all right?” and she said, “Yep.” And then she teared up and said, “It was beautiful.”’

Ross hopes that in time her study will lead to other, larger trials, involving more patients and more therapists, and helping link Australia to the international effort to rehabilitate psychedelic therapy. Her hopes were boosted in March when Minister for Health Greg Hunt announced  a $15 million grants package to research breakthrough therapies including psilocybin, MDMA and the dissociative anaesthetic ketamine for treating debilitating mental illness.

“This is such a fragile re-entry back into medicine,” says Ross more generally. “We’ve got one shot at this and that’s why it will take the time that it takes — because it is so easily demonised. You need one bad experience that’s highly publicised, and then we are back at square one. You’ll see a very, very public and swift political backlash, like we did in the seventies. And then it’s all off.” She picks up the phone. By mid-afternoon she has made her first appointment. All going well, two weeks from now she and Dwyer will sit beside their patient and hand them a small white capsule. After that, who knows? “What they can experience is visceral,” says Ross. “And then that transcendent state which is really intangible. To see someone going through that is just something else. I don’t have —” She pauses, half-laughs. “No words. Enormous privilege is what comes to mind.” •

This essay first appeared in GriffithReview72: States of Mind, edited by Ashley Hay.

The post Love and fear appeared first on Inside Story.

That damage was made more likely by last Thursday’s announcement that the rollout of the AstraZeneca vaccine would largely be restricted to people over fifty because of the risk of a (very) rare blood-clot condition. Major delays to the vaccine program seem inevitable now that the government is more reliant on Pfizer’s overseas-produced vaccine (and possibly the Novavax vaccine, if it is approved) for the under-fifties, rather than the locally produced AstraZeneca. Tellingly, Morrison has abandoned the target date for vaccinating all Australians, which may now extend well into next year.

The damage to Morrison’s standing may be even more serious, as the AstraZeneca debacle raises broader issues about the federal government’s management of the pandemic.

Most Australians (other than those still stuck overseas) will be incredibly grateful that the federal government closed Australia’s borders to non-residents at a time when the World Health Organization was arguing against such an action. Most will also be grateful that the federal government funded JobKeeper and increased payments for JobSeeker (even if JobKeeper has now ended and JobSeeker has been reduced).

Those measures played an essential role in protecting Australians’ health and livelihoods. Decisions by state premiers were crucial, too, not least when they shut their borders after Morrison had urged them otherwise. Australians were left in a much better position than residents of most other countries.

Nonetheless, a number of questions hang over the federal government’s handling of the pandemic.

One relates to the adequacy of stocks of personal protective equipment, or PPE, in the national medical stockpile prior to the pandemic. We now know that those supplies — particularly of the N95 respirator masks that provide greater protection from airborne transmission — were insufficient. This was despite the fact that N95 masks (and eye protection) had played a vital protective role in previous outbreaks, notably with SARS in 2003.

I can testify that Australian travellers to SARS-affected locations overseas at the time were advised to wear N95 masks, although they soon proved hard to obtain, even in countries that were not directly affected by the virus. The Korean MERS outbreak in 2015 provided further evidence that coronaviruses could be airborne. Given that experience, the national medical stockpile should have held a plentiful supply of N95 respirator masks and indeed of any other PPE required.

The federal government deserves praise for following the advice of medical experts from the beginning of the pandemic. But the N95 mask shortage raises the question of whether it was getting advice from a wide enough range of experts, including epidemiologists, ventilation experts and occupational health and safety specialists, regarding whether Covid-19 could be spread by airborne transmission.

After all, Chinese officials had stated as early as February 2020 that the coronavirus could be spread by air. Australian medical experts had become increasingly concerned about the possibility, and about the implications for adequate PPE and infection control. Yet images of staff dealing with potential and actual Covid-19 cases in aged care, hospitals and quarantine hotels while wearing ordinary surgical, rather than the more protective N95, masks were common through too much of last year.

Arguably the spread of Covid-19 in aged care, hospitals and quarantine hotels would have been greatly lessened if the federal government had recognised the possibility of airborne transmission earlier and issued recommendations regarding ventilation, PPE and regular testing of staff accordingly. Aged care and quarantine are a federal government responsibility, and fewer infections, deaths and lockdowns might have resulted. The problems with infection spread were clearly not confined to the actions of poorly trained and precariously employed private security guards. It’s true that the World Health Organization was also slow to recognise the possibility of airborne transmission, but the Morrison government had ignored them on border closures, so why not on this?

Australia would also have been in a stronger position if the government had made more efforts prior to the pandemic to ensure adequate domestic production of both surgical and N95 masks rather than rely on international supply chains, particularly from China. Indeed, a recent Productivity Commission report has identified numerous potential weaknesses in Australian supply chains for essential goods.

The problem with the AstraZeneca vaccine raises issues about why the government didn’t secure deals much earlier with a larger number of potential suppliers, including Moderna, whose vaccine is being successfully rolled out overseas. With countries inevitably competing for limited doses, just as they had for PPE, supply issues were entirely predictable.

Domestic production questions arise here too. The government was right to help fund local AstraZeneca production by CSL (albeit reportedly initiated by CSL after AstraZeneca approached them). But Australia is unable to produce cutting-edge mRNA vaccines such as Pfizer and Moderna, despite experts having urged the government to invest in capacity.

This means that many older Australians who are most vulnerable to Covid-19 are likely to be vaccinated with the AstraZeneca vaccine, with the exception of those aged care residents who were lucky enough to get a Pfizer dose in the 1a rollout. This vulnerable cohort includes many frail elderly people living in retirement villages or in their own homes who weren’t eligible under 1a, as well as other over-seventies who have recently become eligible under section 1b of the rollout.

The fifty-to-seventy age group is also at increased risk of Covid-19’s worst effects, with members of the Indigenous community aged fifty and over at particular risk. Yet the AstraZeneca vaccine may provide significantly less protection against the South African variant of Covid-19 than the Pfizer vaccine that will be given to the less vulnerable under-fifty group, although even Pfizer is not quite as effective against the South African variant as it is against some other strains. Novavax, the third (but yet-to-be-approved) vaccine on order, which may be given to the under-fifties, has claimed efficacy against the South African variant. The Pfizer and Moderna vaccines may well provide more protection generally against the virus.

The government has assured us that currently eligible under-fifties will still be able to choose the AstraZeneca vaccine if they wish, rather than waiting for sufficient Pfizer (or possibly Novavax) doses to arrive. But the vulnerable Australians over seventy, and Indigenous Australians over fifty-five, who are now eligible for the 1b rollout, can’t currently opt for a dose of the Pfizer vaccine, despite it potentially offering more protection. It isn’t clear when, if at all, possible booster shots against Covid variants will be available.

The Morrison government managed to survive deficiencies in its pandemic management last year because Australia has been so successful in suppressing Covid-19. Whether it can survive falling behind in vaccinating the population, with all the economic and health consequences, remains to be seen. At the very least, the government risks alienating two crucial elements of its support base, elderly Australians and business. But many other Australians will be affected too, especially if there is a major Covid-19 outbreak before a successful national vaccination program concludes. •

The post Target trouble appeared first on Inside Story.

The extent of what’s being called vaccine nationalism is clear in the figures. As of early February, more than three-quarters of all vaccinations had been administered in the ten countries that together account for almost 60 per cent of global GDP, leaving some 130 countries, with 2.5 billion people, yet to receive a single dose.

Even before many of the vaccines had completed clinical trials or regulatory approval, the governments of the wealthiest countries had signed agreements with pharmaceutical manufacturers. As a British Medical Journal paper published in December revealed, some 3.76 billion courses (or 7.48 billion doses) of the projected manufacturing capacity of 5.96 billion courses by the end of 2021 were already committed by November 2020.

Of these, a shade over half were allocated to the high-income countries that account for only 14 per cent of the world’s population. Australia, Japan and Canada — countries with relatively small populations and few coronavirus cases — had collectively reserved more than a billion doses. Perhaps 2.34 billion courses would be left for low- and middle-income countries, the authors calculated. By 30 January, Britain had reportedly secured enough vaccines to give each of its citizens five doses, while Canada has ordered enough to give everyone nine doses.

The situation is reminiscent of the 2009 H1N1 influenza outbreak, when a handful of wealthy countries secured most of the vaccine supplies and relatively few of the populations who would have benefited most from the vaccine got it in time to make a difference.

Vaccine nationalism is rarely beneficial in the long run. Modelling by the International Chamber of Commerce shows that the economic benefits of funding equitable access to vaccines dwarf the costs. Advanced economies stand to lose as much as US$4.5 trillion if they fail to give developing economies access to coronavirus vaccines.

That didn’t stop EU health commissioner Stella Kyriakides from threatening to require companies making coronavirus vaccines in the bloc to “provide early notification whenever they want to export vaccines to third countries.” The statement contrasted with pleas for vaccine sharing from French president Emmanuel Macron, German chancellor Angela Merkel and other leaders.

The main international effort to secure equitable and affordable vaccine supplies for all countries, especially the poorest, falls under the auspices of COVAX, a joint initiative of Gavi (a public–private global health partnership dedicated to increasing access to immunisation in poor countries), the Coalition for Epidemic Preparedness Innovations (an Oslo-based fund supporting the development of vaccines against Covid-19) and the WHO.

COVAX aims to build manufacturing capabilities and secure two billion vaccine doses for distribution by the end of 2021. The plan is for more than a billion of these doses to be provided free or at a low cost to ninety-two low- and middle-income countries. The remainder will go to wealthier countries, which will pay for them.

Australia joined COVAX last September with a A$123.3 million commitment to its purchasing mechanism, which will enable Australia to purchase vaccines as they become available. This option may never be taken up, though: it comes on top of the agreements Australia has struck with Oxford–AstraZeneca, Pfizer and Novavax, which together will provide some 120 million doses.

COVAX’s work was initially hindered by the Trump administration’s refusal to participate. That was last September, after it had withdrawn the United States from the WHO, citing the agency’s “China-centric” response to the pandemic. It’s probably no coincidence that China announced its participation in COVAX the following month. In some diplomatic circles its motives for doing so are suspect. Russia, although a major vaccine developer and manufacturer, stayed on the sidelines.

All that changed with the election of Joe Biden, who acted quickly to rejoin the WHO and provide funding for COVAX. He has announced an initial US$2 billion and will release a further US$2 billion over two years once other donors have made good their pledges.

The US funds were appropriated by a bipartisan congressional vote in December — after Biden was elected but when Trump was still in office — and they provided a much-needed boost to the program. Indeed, the decision has been described as a “game changer” that will help mobilise other governments to start contributing to COVAX. The current funding shortfall for coronavirus testing, drugs and vaccines, and the resources to deliver them is estimated at US$27 billion for 2021.

Suddenly Russia, too, is interested in working with COVAX, although it has indicated it will not be substituting COVAX for its supplying of Sputnik V vaccine directly to other countries. China has taken this approach as well, offering priority access to its own vaccines to countries in Africa, the Middle East and Southeast Asia. While less is known about their efficacy, the Russian and Chinese vaccines are considerably cheaper than those produced in the West. These two jousting world powers clearly see their vaccines as a form of soft diplomacy, with more opportunities for this created by Trump’s weakening of America’s international standing and involvement. It is unlikely that the Biden administration will so readily cede this field.

Despite the boost from US involvement and recent pledges for increased support from G7 nations, COVAX faces a huge task in getting the leaders of wealthy countries to deliver their full funding commitments and to match their actions to their rhetoric.

Macron’s rhetoric is a case in point. Supported by Merkel, he called for 3 to 5 per cent of the European and US vaccine supply to be sent to developing countries. Diverting a small percentage of doses would not dramatically affect vaccine rollouts, he said, and would deal with the fear that Moscow and Beijing plan to wage what he called “a war of influence over vaccines.” Direct donations of vaccines, he argued at the Munich Security Conference last month, would be quicker than donating money to COVAX. But it isn’t clear when or even if these donations will happen. The British government said it will “share the majority of any future surplus coronavirus vaccines from our supply” with COVAX but gave no time frame.

Despite the problems, the good news is that vaccines are starting to arrive in Africa. This past week 600,000 doses of the Oxford/AstraZeneca coronavirus vaccine — developed in Britain, manufactured in India, with needles sourced from Dubai and funded by COVAX — arrived at the airport in Accra. This means that Ghana, a lower-middle-income country with a population of thirty-one million, can begin vaccinations this week.

African countries like Ghana have not been hit as hard by the virus as wealthier nations. So far, Ghana has recorded some 82,000 cases and nearly 600 deaths; but now, like many others in Africa, it is experiencing a second wave of infections. Managing the pandemic in Guinea and the Democratic Republic of the Congo has also been complicated by new outbreaks of Ebola.

Experts believe that the emergence of new coronavirus variants has contributed to a new wave of infections in many countries in southern Africa. They are concerned that unequal vaccine supplies and delays in vaccination programs will not only prolong the pandemic but also increase the possibility of hardier, more lethal variants. With more than 130 countries yet to vaccinate a single person, this is yet another reason for concerted international vaccination efforts.

COVAX has no power to compel states to share their surpluses. Some countries, Norway and Canada among them, have committed to sending their excess vaccines to COVAX. Others have used vaccines to advance foreign policy goals (Israel) or placate near neighbours (Spain).

And Australia? Prime minister Scott Morrison initially made a fairly tepid commitment to distributing coronavirus vaccines to the Pacific and some Southeast Asian countries “if Australia develops a supply.” Already, Australia has secured dramatically more vaccine than needed — and is also investing in increased local vaccine manufacturing capabilities — so Morrison should be able to ensure that “we’re doing our bit in this part of the world,” as he said in early February.

International availability of vaccines may also be boosted by cooperative initiatives to lift manufacturing capacity. French pharmaceutical giant Sanofi recently announced it would make its manufacturing infrastructure available to produce the Pfizer vaccine, and US company Merck, whose own vaccine candidates were not successful, has said it is in talks with governments and companies to potentially help manufacture already-approved vaccines. Brazil, China and India all have vaccine industries with enough capacity to manufacture supplies for their own use and for export.

The WHO has called on companies with vaccines to issue non-exclusive licences to allow other producers to manufacture their products, a mechanism that has been used before to expand access to treatments for HIV and hepatitis C.

As countries like the United States, Britain and now Australia are learning, successful vaccination programs require much more than simply getting the vaccines safely to vaccination centres. Trained personnel, technical assistance and equipment are needed, as are careful record-keeping and surveillance, transport and refrigeration. All this is considerably more costly and often more difficult to arrange than the vaccines themselves.

Last May the Australian government redirected A$280 million from overseas aid and humanitarian programs to the international Covid-19 response. Most of these funds (A$205 million) went to the Pacific region for technical assistance and supplies, laboratory diagnosis, personnel and surveillance. The Australian Council for International Development welcomed the decision but decried the repurposing of already-stringent aid funds. Additional resources are required.

The elephant in the room, especially where new vaccines are involved, is who bears the risk of any adverse side effects or injury to patients. Countries funding their own vaccine procurement must also undertake their own liability programs.

In the United States the Trump administration granted companies like Pfizer and Moderna immunity from liability for unintentional problems with their vaccines. It isn’t possible to sue the government or the Food and Drug Administration over side effects either. This rare blanket immunity deal, which extends until 2024, involved invoking the 2005 Public Readiness and Emergency Preparedness Act, which provides legal protection to companies making or distributing critical medical supplies, such as vaccines and treatments, unless there is wilful misconduct by the company. 

The Australian government’s 2020–21 budget included a commitment to provide the suppliers of coronavirus vaccines with indemnity against liability for rare side effects. But experts have pointed out that it isn’t clear what this means in practice, and the government has not released any further details, citing “commercial in confidence” considerations.

The WHO, in what it describes as the “first and only” international vaccine injury compensation scheme, has agreed a no-fault compensation plan for claims of serious side effects in the ninety-two poorest countries due to get coronavirus vaccines via the COVAX scheme. This relieves recipient governments of a potentially serious financial and judicial burden.

Coronavirus vaccines have arrived in record time, and they will have a critical role in bringing the pandemic under control. But population immunity is required to end the pandemic, and this must be achieved internationally if the world and travel and open borders are to return to something like pre-pandemic times.

Achieving that level of immunity will take time and efforts well beyond vaccination programs; it will involve politics as much as science, political will as much as vaccination expertise, and recognition that a global pandemic requires a global response.

To return to the words of the WHO director-general: “Vaccine nationalism is not just morally indefensible. It is epidemiologically self-defeating and clinically counterproductive… Allowing the majority of the world’s population to go unvaccinated will not only perpetuate needless illness and deaths and the pain of ongoing lockdowns, but also spawn new virus mutations as COVID-19 continues to spread among unprotected populations.” •

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

The post Vaccinating the world appeared first on Inside Story.

Now we are in the age of “circuit-breaker” lockdowns. In contrast to the extended lockdowns of waves one and two, which were designed to snuff out invisible chains of community transmission, these short, sharp shutdowns are all about buying time to enable the public health response to get ahead of the virus.

Long lockdowns work by keeping the average number of close contacts low across the whole community, thwarting the virus’s attempts to move through the population. They usually run for six to eight weeks, holding infected people in relative isolation long enough to ensure that entire households are no longer infectious.

Circuit-breakers, on the other hand, don’t need to be in place for even one full incubation period to be effective. They are generally used in one of two ways: to slow an established outbreak or — as has happened four times recently in Australia — to help close down a new outbreak.

If they come early in an outbreak, circuit-breakers can minimise the risk of further transmission while health authorities chase down cases and their contacts and use mass testing to map how far the virus has penetrated. They don’t go on long enough to cause the virus to die out; instead, they keep the majority of the population in something akin to quarantine until everyone who might have been exposed is identified and isolated.

The first of these lockdowns came in Adelaide in November, when a new case appeared to have contracted the virus via a very casual exposure while picking up a pizza. The fear was that the infection might signal a superspreader event, but further investigation revealed he had been exposed more intensively by working at the venue with a known case. When it became clear the outbreak was contained, the six-day lockdown was truncated to three days.

Brisbane came next. A three-day lockdown was declared on 8 January after a cleaner working in hotel quarantine became infected with what genomic testing revealed to be one of the new infectious variants, B.1.1.7. Given the impact of the variant during Britain’s uncontrolled second wave, authorities were worried that it might be more difficult to contain.

As it transpired, we were lucky. Despite being out and about for a few days, the cleaner was not especially infectious and only passed the virus on to her partner. The rapidly implemented precautionary lockdown was, thankfully, not needed. But that also meant contact tracing was not tested in those circumstances, so we don’t know whether it alone might have been sufficient to contain the potential outbreak even if the index case had been more infectious.

Next came Perth. Four days after announcing a hotel worker had tested positive for the same B.1.1.7 variant, the WA government sent the city and parts of the state’s southwest into a five-day circuit-breaker lockdown at the end of January. Once again, the concern over the potential impact of this strain on outbreak containment led to this significant step.

Luck was once again on our side. No secondary transmission had occurred, not even to close contacts. This is typical of the virus — 20 per cent or so pass it on; most do not. Once again, the circuit-breaker proved to be an unneeded precaution. Even though they hadn’t needed to deal with wider community transmission, the Brisbane and Perth circuit-breakers were labelled a “success.”

But these events will provide rich information to determine whether the lockdowns added necessary additional containment, or whether contact tracing alone was coping. We will be able to determine whether all contacts were in quarantine before the lockdown came into effect, for example, or before they could have been infectious.

We now have more detailed data from Britain on the increased infectivity of B.1.1.7. Public Health England reported that 14.7 per cent of close contacts of cases became infected compared with 11 per cent for previous variants. This 34 per cent acceleration in new cases has proved devastating in countries where the variant now dominates, and demonstrates why we must not let this (or other) mutant variants escape into the community in Australia.

The good news is that even with these higher infection rates, we can contain outbreaks if we catch them early. If ten cases each have ten close contacts, we might see fifteen secondary cases on average, instead of eleven. That is manageable with contact tracing. Yet when Victoria experienced its latest crossover into the community from hotel quarantine, again involving the B.1.1.7 variant, the entire state was placed into a five-day lockdown.

In this latest event, still playing out as I write, other factors had to be considered. Four staff were infected in quick succession in hotel quarantine, along with two returned travellers sent home before the outbreak was detected. In other words, six people were potentially seeding community outbreaks simultaneously: six more chances of a highly infectious case within one generation of spread. No wonder authorities were nervous.

As it stands, four of those initial six cases didn’t pass on the virus. Of the other two, one infected a spouse only and the other, unknowingly infectious, attended a large family event that led to a second-generation of spread of seven further cases. This dinner occurred before the outbreak was apparent, and six full days before lockdown started.

That family dinner is now the central concern. All attendees have been identified, tested and isolated, but the seven new cases resulting from this exposure event were potentially infectious for up to four days before they were identified as close contacts of a known case. If none of their close contacts tests positive, we can relax; the risk that they may have passed the virus on to more casual contacts is then significantly less.

Will the circuit-breaker lockdown contain transmission in Victoria? It couldn’t prevent the secondary community transmission because the exposure occurred too early in the chain of events — before the hotel worker who seeded the outbreak was recognised to be a case, and before the infected person’s last workplace test yielded a negative result.

That person must have been becoming infectious at the time of the family dinner, but their fluctuating viral load produced a very weak positive result a day later, insufficient to register as a positive result the first time the sample was tested. The event was not recognised as an exposure site for another five days.

That will be the true test of whether we need circuit breakers. We can learn from this latest public health response, as well as the previous ones, whether we can rely on contact tracing even in the face of more transmissible variants in a more complex outbreak. If lockdown does help quash further spread — and we will know that soon enough — we can then use this information to inform future decisions on when circuit breakers should be used, and what they need to involve.

Building on the “success” of the previous, untested lockdowns — lockdowns that have progressively been extended in both duration and geography — is dangerous. We risk believing they are an essential tool when in fact they had nothing to do with the outcomes in Queensland and Western Australia. The next few days will add the Victorian experience to the mix, and even if this lockdown ends up being redundant, we will have learned more valuable lessons. •

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

The post The circuit-breakers appeared first on Inside Story.

The United States is the stand-out failure. For decades, enormous spending on healthcare has failed to produce better health and longer lives than in many other countries that spend less. Covid-19 has added hugely to the mortality toll, with a disproportionate number of deaths among already-lagging minority populations. But even before the pandemic, average life expectancy in the United States, and in Britain, had fallen in recent years.

Life expectancy is the traditional broadbrush measure of population health. It gauges the effectiveness of the healthcare system and the effectiveness of healthcare spending. But it also gauges the impact of the social determinants of health — poverty, housing, education, discrimination and other non-medical factors that play a major role in health and wellbeing. Because life expectancy figures are an average across the population, some groups could actually experience decreases in a particular period while the population as a whole is going forward.

On the basis of the 275,000 US deaths attributed to Covid-19 by early December (the figure is now more than 470,000), University of California researcher Patrick Heuveline estimated average life expectancy for American babies born in 2020 to be lower by more than a year, the biggest fall since the end of the second world war. Heuveline compared the expected mortality rate in 2020 with the actual rate, which included deaths from Covid-19 and the “excess” deaths among people who didn’t get necessary medical care. The more young people are affected, the worse the impact on life expectancy. By comparison, the HIV epidemic reduced the US life expectancy at birth by 0.3 years at its peak in 1992. Covid-19’s impact on US mortality can be expected to cancel a decade of reductions in all other causes of mortality combined.

These findings are confirmed and extended in a study published just this month. American researchers Theresa Andrasfay and Noreen Goldman estimate that US life expectancy at birth has fallen by 1.13 years, to 77.48 years, lower than any year since 2003, and they project a 0.87-year reduction in life expectancy at sixty-five. The African-American and Latino populations, which have experienced a disproportionate burden of Covid-19 morbidity and mortality, are estimated to experience declines in life expectancy at birth of 2.10 and 3.05 years respectively.

This has the effect of increasing the Black–white life expectancy gap from 3.6 years to more than five years, eliminating the progress made in closing the gap since 2006. Latinos, whose mortality rates are consistently lower than white Americans’ (a phenomenon known as the Hispanic paradox), will see their three-year-plus survival advantage reduced to less than one year.

The picture is almost certain to look bleaker in 2021. Further reductions in life expectancy can be expected beyond 2020 because of continued Covid-19 mortality and the long-term health, social and economic impacts of the pandemic. Moreover, most epidemiologists consider that the number of infections in the United States has been severely underestimated and that excess mortality (deaths from causes other than Covid-19) will be higher with hospitals and healthcare systems operating under pressure.

The United States is not the only country to have suffered such a setback. Life expectancy will fall in any country or region that has experienced a coronavirus infection rate higher than 1 per cent, especially if the mortality rate in younger patients is high. A 10 per cent Covid-19 prevalence rate in North America and Europe means a loss of at least one year of life expectancy at birth.

In Bergamo in Italy’s Lombardy region, where serological tests have shown a 50 per cent infection prevalence rate, a group of European researchers has estimated a loss of life expectancy of 4.1 years for men and 2.6 years for women. (In this case the measure is average life expectancy for the population as a whole, so direct comparisons with US findings are not possible.) Demographers at Oxford University’s Leverhulme Centre calculate that life expectancy for both men and women in England and Wales was reduced in 2020 by more than a year (one year for women and 1.3 years for men) as of December 2020, wiping out gains made on life expectancy in the past decade. Australia has escaped this trend, thanks to low infection rates and a high concentration of deaths in the oldest age groups.

For Americans, this dismal news comes on top of several decades’ evidence that life expectancy at birth is lagging, the existence of a large and rising “mortality gap” between Americans aged fifty and older and their international peers, and data showing that even highly advantaged Americans are in worse health than their international peers.

In 2013 the US National Academies of Science (then the National Research Council and the Institute of Medicine) issued a report, Shorter Lives, Poorer Health, that ranked the United States last in life expectancy for men and second-last for women among high-income countries. Edward Alden of the Council on Foreign Relations described the report’s findings as “a catalogue of horrors.” (I was commissioned by the Institute of Medicine to write a discussion paper, Reducing Disparities in Life Expectancy: What Factors Matter?, for the report.)

The research team that produced Shorter Lives, Poorer Health aimed to elucidate why the United States suffers the health disadvantages it documented. Common explanations — obesity, lack of access to healthcare, health disparities between population groups — were all at play, but the exact cause, or combination of causes, wasn’t clear.

Despite the glaring deficiencies this report exposed, the situation has only worsened. The United States now ranks forty-third out of 195 countries for life expectancy at birth (Australia is fifth). In the absence of significant action, is expected to rank sixty-fourth by 2040. The figures are worse for African Americans, Native Americans, and people in poor and rural areas. The US maternal mortality rate ranks last among similarly wealthy countries and its infant mortality rate thirty-third out of thirty-six OECD countries. Many Americans are not living to see old age; the United States has consistently had the lowest or second-lowest probability of surviving to fifty.

The overall pace of mortality improvement has slowed in a number of European countries, and even in Australia, over the past decade. Dementia is the major contributor, along with rising obesity and diabetes and adverse trends in inequalities. The distinguished epidemiologist Michael Marmot succinctly outlined the challenges for Britain — but generally applicable in other developed countries — in his Marmot Review 10 Years On last February.

While access to healthcare is important, it contributes only modestly to longevity. Between a third and a half of these life expectancy gaps are explained by differences in the social determinants of health, including rates of poverty and educational disadvantage.

Poverty has a major impact on health and premature death. The longer people live in disadvantaged circumstances, the greater the risk of ill health. People who are unemployed, and the families of those who are unemployed, experience a much greater risk of premature death. Education is also key. Highly educated adults in the United States have lower yearly mortality rates than less-educated people in every age, gender and racial/ethnic subgroup of the population. These differences are somewhat wider among men than women.

The United States is also confronted with rising mortality rates caused by alcohol, drug overdoses, the opioid epidemic, gun violence and suicide. These “deaths of despair” are exacting an increasing toll on middle-aged, non-Hispanic white Americans, especially those without a college education. Indeed, the most meaningful risk factor for such a death is not having a university degree.

It’s not hard to see how these risk factors were all in play during the pandemic, with access to healthcare and social services more important than ever, employment and income at risk, and the demoralisation and grief brought on by the loss of jobs, social contacts and loved ones. The Trump administration must obviously be blamed for the pandemic’s disastrous impact in the United States, but the foundations for failure were decades in the making. The Shorter Lives report’s catalogue of horrors was a harbinger of things to come.

In the search for answers about inequalities, the report contains a final chapter (regarded by the research team as almost an afterthought) that discusses whether values seen as typically American — individual freedom, free enterprise, self-reliance, a major role for religion, federalism — influence the development of policy and its enactment in ways that are detrimental to Americans’ health.

Recent analysis of state politics and policies has found that American states with more progressive policies have longer life expectancy rates than those with more conservative policies. On this measure, American states have increasingly diverged since the early 1980s, shortly after the federal government began transferring policymaking authority for Medicaid and welfare programs to them. In 1959 Connecticut and Oklahoma had the same life expectancy; by 2017, Connecticut had gained 9.6 years while the more conservative Oklahoma had gained just 4.7.

The researchers estimate that if all states adopted policies similar to those of Hawaii (which has strong laws on labour rights, prohibiting tobacco and environmental protection, and a healthcare system that acknowledges the Native Hawaiian culture), US life expectancy would be on par with those of other high-income countries. These findings are partially countered by an analysis that found even if everyone achieved the health outcomes of white Americans living in the richest counties, health indicators would still lag behind those in many other countries.

The relationship between politics and health is also reflected in voting patterns. In 2016, counties with stagnating or falling life expectancies were more likely to vote Republican. This aligns with the strong support for Trump and Republicans among white Americans without a college education. Many of these Republican-voting areas are now also those with the highest infection and mortality rates from coronavirus.

For president Joe Biden and his team, these data highlight the size of the task ahead. Primacy, of course, must be given to controlling Covid-19, getting everyone vaccinated, and tackling the pandemic’s economic fallout ahead of boosting access to healthcare (including mental health and substance abuse services), housing, employment and education. But if these efforts are not targeted at the most needy communities they will simply widen existing socioeconomic gaps.

There are lessons in these figures for Australia, too. The pandemic has highlighted the inadequacy of the social services safety net — hence the large but temporary lift in the JobSeeker rate — along with the fragmentation of the healthcare system and the widening health disparities. For too many Australians life expectancy is a postcode lottery. For Indigenous Australians the life expectancy gap has not narrowed since 2006.

Better health is undoubtedly related to social expenditure, and social protection may be more important for health outcomes in more unequal societies. In a recent edition of the Medical Journal of Australia, Shane Kavanagh, Anthony LaMontagne and Sharon Brennan‐Olsen warn of the likely impact of calls to prioritise rapid reductions in government debt through cuts to health and social services. Government spending on health, education and social supports has the potential to increase economic growth, they argue, and “avoiding austerity measures will better serve the health of Australia’s population, and indeed the health of the nation.”

The political preference is too often for policy solutions that are readily to hand and simple. A medicine that allows patients to live with diabetes is seen as a more desirable announcement for the health minister than the grinding job of changing food and exercise policies so that fewer people are overweight and prone to the disease. Evidence from the United States suggests that policies on tobacco, labour, immigration, civil rights and the environment appear to be particularly influential for life expectancy.

It is shocking how quickly the hard work of improving life expectancy can be overturned. But there is also evidence that better policies can turn things around relatively quickly. Within four years of the introduction of mandatory health insurance, known as Romneycare, in Massachusetts in 2006 the death rate had fallen by 3 per cent, with the steepest declines seen in counties with the highest proportions of poor and previously uninsured people.

Joe Biden has committed to tackling the social inequalities and inequities in the United States. He quickly appointed a White House health equity task force headed by physician Marcella Nunez-Smith, which will make recommendations on mitigating and preventing health disparities. The task force’s initial focus will be on the equitable allocation of resources, vaccines and relief funds to deal with the pandemic.

The new president has also signed executive orders aimed at improving racial equity across the nation. These include measures to strengthen the anti-discrimination housing policies weakened under Trump and to enhance the sovereignty of Native American tribes. More far-reaching changes are expected in the months ahead.

Biden says he plans to infuse a focus on equity into everything the federal government does. All Australians — but especially those whose lives are shortened and diminished by the lack of an adequate income, housing, education, healthcare and employment — would benefit from a comparable commitment from Scott Morrison and his government. •

The post When wealthier doesn’t mean healthier appeared first on Inside Story.

Over the next few weeks we’ll be featuring selections of summer reading from our twelve years of archives — and, of course, highlights from 2020, the year of bushfires, Covid-19, a government that’s taking a long time to wake up to the looming post-carbon reality, and much else.

We’ll be back in full swing at the end of January. In the meantime, have a happy and safe holiday season. •

The post Inside Story’s summer season appeared first on Inside Story.

Not that they were failures for which blame could always be attributed. The limits of human vision and agency must be confronted in any disaster, and Black Summer, the first episode of the year, presented the confrontation as a very immediate ordeal, terrifying to witness even in its aftermath. The program was introduced by Hamish Macdonald, who was himself caught up in the unfolding catastrophe in Cobargo on the NSW south coast, and footage was provided by people struggling to get their bearings in the midst of the inferno. With sparks flying from all directions as the fire front approached in the opening scene, a voice-over at least provided reassurance that we were in the presence of a survivor: “The sky was changing colour… It just got darker and darker and darker.”

“There are known unknowns,” as Donald Rumsfeld famously said, “and there are also unknown unknowns.” The fires were a known unknown. Rural fire brigades knew that conditions were stacking up for a worst-case scenario; fire chiefs issued dire warnings to the government. But no one could know how, when or where the emergency would present itself. When outbreaks began to multiply, news commentators spoke of “uncharted territory.” As for dealing with the human aspects of the tragedy, Shane Fitzsimmons, head of the NSW Rural Fire Service, put it best: “there’s no rule book, no script, no guide.”

The fire itself was a demon of unpredictability, changing course, creating its own weather, eliminating so many features of the natural world that people trying to flee couldn’t see or hear anything else. Vehicles were driven in conditions of near-zero visibility; a fallen tree across the road could prove fatal.

Twenty-twenty vision is a luxury we don’t always have, and having to do without anything resembling it was one of the lessons of the bushfires. “It’s going to be a turning point for everyone in Australia and a lot of people worldwide as well,” said a Kangaroo Island survivor in the closing moments of the program.

If that’s the case, we have yet to reckon with it. Hard Winter, a follow-up on bushfire recovery screened in June, showed the communities of Cobargo, one of the worst-affected areas, struggling on their own. A couple are seen pulling a tarpaulin over a makeshift shelter on a property surrounded by blackened trees. With no running water, they must drive to the village to take showers. Fuel is a scarce commodity. Five months on, basic needs were still not being met.

The government bodies, charities and services supposed to be helping were simply not equipped to respond adequately, and had failed to factor in the psychological gap. Presenting application forms to traumatised people who have lost everything is crassly inappropriate; a $50,000 rebuild grant for an uninsured farmer living amid the burnt-out ruins of a lifetime’s work is cruelly inadequate. Post-traumatic stress may kick in several months after the event, once the mental health counsellors have packed up and left.

But the turning point seemed not to have registered in the national psyche. Only those at the centre of the disaster were facing up to a changed reality. “We’ve lost our innocence, our ‘she’ll be okay mate,’” said a local business owner. “Because it’s not. And it won’t ever be.” “Be with us. Work with us. Stay with us,” another resident pleaded. Some have stuck around, like the volunteer backpackers who helped a farmer replace kilometres of fencing, but elsewhere other concerns were coming to the fore.

By late February, the pandemic was taking over from the bushfires as the crisis of the year. In Coronavirus (24 February), Sean Nicholls reported from Wuhan with footage of a deserted metropolis that presaged what was to come in cities around the world, though at the time it seemed an extreme symptom of some alien regime of power. The virus was another known unknown, with comparisons to be made with SARS, HIV/AIDS, Ebola and the Spanish flu.

If there were any unknown unknowns, they were in its place of origin — this great oriental city under the control of a government increasingly perceived as hostile and secretive. What was really going on in those sinister scenes of white-suited men hauling citizens out of their houses and bundling them into official vehicles? Terrified residents found themselves locked in their apartment buildings; people were said to be dropping dead in the streets; doctors were being threatened for sharing information about cases they were seeing.

Xi Jinping had lost control of the narrative, said the Lowy Institute’s Richard McGregor. And as for the infection rate and mortality numbers, who knew for sure? According to Neil Ferguson, professor of epidemiology at Imperial College in London, up to an estimated 50,000 people were being infected each day in China. Official figures were reckoned to reveal less than 10 per cent of the actual rates. If the Chinese government was underestimating at that stage, Ferguson’s numbers were wildly overestimated.

In hindsight, the program had some troubling elements of xenophobia. How different does all this look when we take the Orientalism out of the picture — when it is the deserted streets of Paris and Rome on our screens; when the US administration has lost control of the narrative; when an apartment block in Melbourne is suddenly cordoned off and Sky News stirs up alarm about Dictator Dan?

Pandemic (30 March), was the first attempt to report on the virus from an Australian perspective. Sean Nicholls, again the principal reporter, opened by announcing that Australia, like much of the world, was “on a war footing.” Norman Swan, reporting from the frontline, was measured and genuinely informative, as he has been throughout the pandemic, but the spectre of disaster on an unpredictable scale loomed.

Every infected person would infect two others, said Sharon Lewin, director of the Doherty Institute. That is theoretically possible, though not a standard expectation by any means. As the program went to air, the Ruby Princess debacle was unfolding and the prime minister had been forced to do a swift reversal on pronouncements made two weeks earlier about freedom to go to the footy. On social media, “2020 vision” was becoming a bad joke.

As might be expected, the pandemic dominated the Four Corners agenda for the rest of the year. Episodes focused on the financial implications, on the Ruby Princess, on vaccine research, on the second wave, on infection spread in aged care facilities, and on the impact of school closures on Year 12 students. As the year progressed, reporting became less speculative, less foreboding and more focused on the specific ways in which the pandemic’s impact was being experienced.

Students interviewed for The Class of 2020 (2 November) talked of how the lockdown had brought them to reflect on their futures in sterner ways. A confrontation with the unexpected can create a steep learning curve. “This year targeted everything I took for granted,” said Joseph Hathaway-Wilson. Like the woman in Cobargo who spoke of a lost innocence, these students were coming to terms with the limits of human foresight.

Those limits can be a challenge for even the most hard-bitten investigative reporters. A Careful War, a two-part series on the war in Afghanistan originally broadcast in 2010, was promoted again on the Four Corners site earlier this year. It was a remarkable piece of reporting by Chris Masters, embedded with Australian Special Forces troops, who provided live documentation of engagements with the Taliban, including an incident in which two Australian soldiers were killed by an improvised explosive device.

This was the blackest day for Mentoring Team Alpha, which was on a mission to provide security and reconstruction to communities in the remote Mirabad Valley. At the start of the enterprise, morale was high. “Shifting schisms and alliances” was the name of the game and, as commanding officer major general John Cantwell put it, it was not one for sledgehammer tactics: “It requires understanding, nuance, and a sense of affiliation.”

It also requires stepping carefully across every metre of ground. What the troops could not determine, often because the locals wouldn’t tell them, was where the explosive devices were buried. Always, there are known unknowns. And for Masters himself, there was a residual awareness of another side to the military story, which he has subsequently taken a lead role in exposing. The darker picture emerged with devastating impact in Killing Field (16 March), based on footage captured by soldiers in Afghanistan. Mark Willacy obtained extensive interviews, most notably with Braden Chapman, an operative deployed with the elite Special Forces in 2012.

From the opening frames, with a soldier’s voice shouting “Get the fuck out!” while frightened civilians were herded from their homes, it was clear we were in a very different environment from the one Masters had documented. Everything was reversed. Here, it was the Australians who were the danger to local communities, and the soldiers themselves had little to fear. “You definitely feel confident with these guys,” said Chapman, “I never felt like we weren’t gonna get through it.”

Chapman is an impressive witness, determined to say what needs to be said despite not knowing how he will get through whatever may be in store for a whistleblower. He had distressing stories to tell, in detail, and the program-makers illustrated them with expertly edited footage that gave a sense of events unfolding in real time.

By the time the episode went to air, allegations of war crimes committed by Australian Special Forces were the subject of an inquiry by NSW Supreme Court judge Paul Brereton. Four Corners reporting, and the work of Masters and Willacy in particular, has a prominent place in the log of evidence.

Amid the global crises and the mounting chaos in the United States, domestic politics registered less strongly than usual on the current affairs radar. With little to be reported from a deserted Parliament House, Louise Milligan’s attempt to portray the building as a scene of scandalous affairs in Inside the Canberra Bubble (9 November) was ill-timed. Why at this moment, when the fallout from the US presidential election was dominating the news, the second wave of the pandemic was building across the globe, and fears of an economic depression were being rehearsed in the press?

It’s not that the issues lacked importance. But the program was made up of a jumble of concerns about personal behaviour, the professional culture of Parliament House (or lack of it), the proportion of women on the frontbench, sexual discrimination and workplace management. The behaviour of senior ministers raises one set of concerns; how workplace conditions are managed and regulated raises another. Why was there no interview with the Clerk of the Senate, who has oversight of human resources?

The program was poorly structured, strung together with a mish-mash of visual footage that might have been assembled from discarded offcuts. Ominous music accompanied panoramic shots of night-time Canberra. The camera peered up the hill towards Parliament House at dusk. Headlights swerved in the darkness. A full moon loomed. All this created a portentous mood, as if to suggest that Canberra is a sinister place and Parliament House — “a bubble within a bubble,” as Malcolm Turnbull put it — a secretive bastion where all manner of things go on.

As for what was actually happening inside the building, the answer was not much, at least at the time. Close-up shots of feet walking down corridors became a kind of leitmotif. They were anonymous and out of focus, and there were high heels in the mix, evoking a stereotyped female corporate look. A few days after the program went to air, it was a relief to see Penny Wong being presented by her colleagues with a birthday present of Converse sneakers of the kind worn by Kamala Harris.

Four Corners doesn’t often fall short in its endeavours. The program continues to make an essential contribution to national affairs. Time and again it has broken stories that spark major public enquiries and legislative changes, and this year was no exception. It’s in periods of turmoil and crisis that its role is most valuable. No government should be allowed to put such work at risk. •

The post Known unknowns appeared first on Inside Story.

Let that soak in. This year, Victorian government spending will grow by more than 25 per cent. The additional spending will amount to close to $3500 for every man, woman and child in the state. That’s roughly $70 per person, per week, in new spending.

There are tax cuts too, but they are dwarfed by the new spending. If the Morrison government’s budget relies too much on tax cuts to stimulate consumer spending and business investment, the Andrews government’s budget does the reverse: just as its coronavirus strategy was an extreme in top-down control, so is its economic strategy.

Most of that is genuine stimulus: one-off measures in response to the economic devastation of the state by months of lockdown, such as a single line item in the budget papers, with no further breakdown, assigning $2163 million to “business support.”

Some of it is transport and other investment proposed for other reasons, but brought forward as a stimulus to economic activity in a year in which Victoria’s gross state product, even on optimistic assumptions, is projected to be 4 per cent lower than a year earlier. That includes $2.7 billion in this fiscal year that will rapidly, if only briefly, scale up the previously pitiful level of state investment in social housing.

And some of it is not stimulus at all, but uses the cover of stimulus action to step up Victoria’s routine budget spending in areas that interest Labor activists, and to commit to long-term infrastructure investments that would almost certainly fail a genuine cost–benefit analysis.

In short, there is much to praise in this budget, but also much to regret. That includes the government’s commitment to build the worst transport project Melbourne has ever seen: the so-called Suburban Rail Loop, in reality a twenty-six kilometre tunnel under the middle southeastern suburbs from Cheltenham to Box Hill. Tunnels eat money, and the demand for this one is likely to be small. No business case has been produced, and no cost–benefit analysis, but it will cost taxpayers tens of billions of dollars.

It is not the first lemon a Victorian government has tried to sell to voters. The Andrews government won power in 2014 partly because the Liberals thought it would be a great idea to spend $7 billion of taxpayers’ money to build a 4.4 kilometre tunnel under the inner suburbs to link two freeways; the taxpayers disagreed. But the Suburban Rail Loop is the lemon that makes other lemons taste like oranges.

Not surprisingly, the ratings agencies yesterday implied that this budget could lose Victoria its AAA credit rating. Standard & Poor’s said there was a 50–50 chance that the state could be downgraded, and this would happen if it came to the view that “the state’s financial management has weakened.”

Well, with respect, it clearly has: as far out as 2023–24, well past the time for stimulus, the budget projects $3.6 billion a year of new routine spending — $1.6 billion of it net of spending cuts and contingencies allowed for in the budget — plus roughly $6 billion a year of additional investment in assets.

Stimulus is certainly what Victoria needs right now, and this budget delivers it. But it has to be paid for, just as investments in roads, rail, schools and hospitals all have to be paid for one day. Governments should be brave and bold about delivering stimulus at this time. On that front, this budget succeeds admirably.

But equally, governments should be wary about the long-term costs of doing so, knowing that the bills will come in at some point, to be covered either directly or through permanently higher interest bills. They should not use the cover of stimulus to smuggle in a step-up in spending levels, and they need to prioritise asset investments that will deliver most bang for buck. This budget fails on both counts.

A bit of background is necessary here, because Twitter gives me the impression that many Victorians have little idea how different their state’s economic position is from that of the rest of Australia. Not only was Victoria home to 90 per cent of the Australians who died of coronavirus, but even after the unexpectedly large rebound in jobs last month, the state accounted for 94 per cent of Australia’s net loss of jobs in the year to October: 124,000 jobs lost in Victoria but just 8000 in the rest of Australia.

Female employment year on year grew by 24,000 in the rest of Australia, but shrank by 105,000 in Victoria, where hospitality and entertainment were largely shut down. For the same reasons, employment of workers aged fifteen to twenty-four shrank by 4000 in the rest of Australia, but by 92,000 in Victoria.

We won’t know the full devastation of lost businesses until JobKeeper ends, but the intensity and duration of Victoria’s lockdowns make it likely that it will also lose more workplaces than the rest of Australia combined. Even with that massive increase in state government spending, projections by the Victorian Treasury and its federal counterpart together imply that while Victoria’s output this fiscal year will be 4 per cent lower than a year ago, output will be only marginally lower in the rest of Australia.

And even that forecast relies on the government’s huge spending increase igniting an extraordinarily rapid recovery. The budget projects that real gross state product will grow by 9 per cent over the course of 2021, the sort of growth rate normally claimed only by China. And most of that would happen in the first half of the year — assuming no more coronavirus and no more lockdowns. As financial market insiders would put it, the risks in that forecast are on the downside.

The level of stimulus is extraordinary, however, and it’s welcome. Unlike the Morrison government, the Andrews government is doing as economists have suggested. In response to the slump in housing construction, it has introduced several new policies, but the big one is a crash program of building social housing, for which waiting lists now extend many years. The promise of another 9000 homes for some of those unable to afford secure and suitable housing in the private market is a marriage of good economic and social policies.

One hopes the government will not then just revert to the inadequate investment levels of the past, as the Gillard government did when Kevin Rudd’s 2009–10 public housing stimulus expired. In fairness, this depends even more on what the federal government is willing to do — which, at present, is not much.

The budget also commits $250 million to the Grattan Institute’s proposal for a two-year program to hire tutors to help struggling schoolchildren catch up, particularly those most affected by the lockdowns. While most stimulus programs, including new infrastructure, provide jobs for blokes, this one will provide much-needed jobs for women.

The budget also envisages lifting the current level of infrastructure spending by almost half, which would be welcome if it also included a transparent, independent way of selecting priority projects. No such luck. In Victoria, as elsewhere, the choice of projects is driven by what the government thinks will give it the most political bang for buck. What will give Victorians the most social/economic bang for their buck is irrelevant.

The Victorian Liberals are still clinging to the East West Link as their branded project, even though it has twice been rejected by the voters and three times by cost–benefit analyses. Labor has done much better with its branded project of removing level crossings, but with that scheme now growing familiar, Andrews has been keen to find a new project.

The federal Liberals have focused on getting a train line built to Melbourne Airport. It might not be needed — it will offer no more than Skybus already provides, except easier access from other suburban lines — but the polls show it is the top project among voters. Saturday’s agreement between the Andrews and Morrison governments means it will now become reality, with the two governments adopting the cheaper of two alternative proposals. The cost is pencilled in as $10 billion, and the completion date as 2029.

Andrews’s own new branded project, however, is the Suburban Rail Loop. It appears that this emerged from his political circle rather than from the railways, let alone transport economists. As originally presented, it was intended to run for ninety kilometres around Melbourne’s middle and outer suburbs, largely in tunnels, with a number of stations in the southeast but very few in the west. The cost was claimed to be $50 billion, which no one believed.

But the government is now proposing to build only the southeastern quarter of the loop, running underground from Southland shopping plaza through Monash and Deakin universities and selected suburban shopping centres (which developers own the redevelopment rights, I wonder?) to Box Hill station in Melbourne’s Chinese heartland.

The budget commits $2.2 billion to the initial stages, primarily for planning, land purchase and so on. Treasurer Tim Pallas promised that a business case will be presented next year, and no contracts for construction would be let until the voters have their say at the 2022 election.

Even the cost of this twenty-six kilometre tunnel might well be $50 billion: no one knows, including the government, which has committed to build it regardless. It is economic lunacy to choose infrastructure projects in this way. Infrastructure Victoria, which was set up to provide objective advice to the government on priorities, has been ignored and sidelined.

No government can build every project we want: it has to prioritise, and select which projects will give the community most value for money. Building the Suburban Rail Loop means the government will not have the resources to take up other, more urgent projects such as the second line of the Metro, intended to run from Clifton Hill to the massive redevelopment site of Fishermans Bend.

Choices have implications. In the ACT, the Labor–Greens government had to shelve its hospital redevelopment plan for a whole four-year term to pay for its own branded infrastructure project, Canberra’s first tramline. The huge cost of building a long underground railway to meet scant demand will push many other projects to the sidelines, possibly for decades.

It would be welcome if, in 2022, the Liberals ditched the East West Link and promised instead to ask Infrastructure Victoria to carry out cost–benefit studies of the key infrastructure choices under discussion. Get the facts, then decide. By contrast, the Andrews government has taken its lead from the Queen of Hearts in the trial scene of Alice in Wonderland: “Sentence first — verdict afterwards.”

The Suburban Rail Loop is the prime example of a problem that afflicts not only the Victorian budget but also Australian politics generally. Just as the hard right sees every issue through the prism of its fixation on waging culture war, so governments focus on what they brand as their projects, and which projects are politically rewarding to announce, rather than on delivering services to us that provide the best bang for buck.

Then, once the political gains of the announcement have been banked, they lose interest in delivering outcomes. The $5 billion the federal government promised for projects in northern Australia, and failed to deliver, is a classic example. But all governments now make wide use of another form of it: financing new projects by “reprioritising” old ones.

This budget has a beauty: a one-line item “reprioritising” $1836 million (2 per cent) of government spending this year alone, and a similar amount over the next three years. It was obscured so well in the budget papers (as one line in table 4.5 of Budget Paper 2) that as far as I can see, no one in the mainstream media reported it. It’s a way of saying: “Oh, by the way, $3.7 billion of the spending we promised you in past budgets won’t be delivered. But just look at what we’re offering you this time!”

There is no information on what past promises have been discarded in this way. It’s politically much easier to make spending cuts that are not announced than to make ones that are. This budget appears to have no announced spending cuts, but if you can cut 2 per cent from spending without announcing what you have cut, why go to the trouble of being transparent about it? This is an issue that oppositions and transparency reformers need to focus on.

One of the budget papers was also discarded: the old Budget Paper 4, the detailed statement of the government’s investment program. Treasurer Pallas blamed the rush of getting the budget ready, and promised it would be back for the budget next May. We have to take him at his word, but the issue matters.

Among other things, BP4 told us exactly how much the government has spent, is spending, and plans to spend on each project, and when it is expected to finish. It is the annual fessing-up to any blowouts in cost or completion dates. It is also a full account of the government’s investment priorities. It should be required by other governments as well, not least the federal government.

It’s also notable that policy commitments are now being made under increasingly long timespans, to make them look bigger. The budget papers tell us Victoria has now committed to $134 billion of new investments, which is roughly ten times the level of its annual investment up to now, and seven times the level projected from here on.

There is only one tax rise in this budget: the little tax on electric vehicles ($250 a year for fully-electric vehicles, $200 for hybrids) to ensure that they pay something towards the cost of providing the roads they drive on. This has provoked predictable outrage, but I seriously question whether it will change anyone’s decision on whether to buy an electric car. Pallas said yesterday that Treasury assumes it will have no impact on vehicle demand.

Politically, despite all the problems it has/had created with Covid-19, the Andrews government remains dominant. This budget comes at the midway point of its four-year term, and the polls tell us Labor would comfortably win any election held now. The apparent eradication of the virus, at least while Victoria was isolated from the world, has turned a looming disaster into a political triumph.

Coronavirus is an ongoing story, with more twists and turns to come. Economic concerns have been ignored by Victorians and their government, but they will become more prominent as fears of the virus recede. This budget seems to leave out nothing in its willingness to lift the economy out of recession through government spending. But I did find one place where the government had exercised spending restraint.

On the same page as the commitment to spend $2200 million on the preliminaries of the Suburban Rail Loop, the government has committed to spend just $4 million over the next four years to improve bus services — the form of public transport that residents of the outer suburbs most rely on. •

The post Stimulus, and more, for Victoria appeared first on Inside Story.

He’s probably right. This huge report draws on a record number of submissions, a series of roundtables and public hearings in all states and territories, and input from a range of eminent experts. It makes more than one hundred recommendations to help the one in five Australians experiencing mental illness every year. It provides a strong economic case for reducing the direct economic costs of mental illness — between $43 billion and $70 billion each year — and the additional $151 billion lost to disability and premature deaths.

So why do I have a feeling that the report’s recommendations might go nowhere?

The fact is that we have thirty years of evidence that official inquiries into mental health — thirty-two of them between 2006 and 2012 alone, according to one observer — rarely lead to major changes. The pattern goes something like this:

• A new health minister recognises the need to do something about mental health but struggles to find a clear direction through the maze of conflicting viewpoints and previous reports. She or he does what any new minister would do in this situation and sets up an inquiry.

• This inquiry takes up considerable time, energy and resources only to confirm the key finding of previous reports — that the problems in mental health are deep and systemic and have no easy solutions. The report recommends a level of spending that makes the treasurer of the day go weak at the knees.

• The health minister is stumped by most of the recommendations in the report because they require feats seemingly impossible in Australian politics (upsetting doctors, working collaboratively with the states, coordinating action across portfolios). While she or he comes to terms with the fact that there’s no chance of getting enough money out of Treasury to implement the recommendations, stakeholders start competing for what they perceive to be a dwindling pool of new funding. The in-fighting quickly becomes personal and nasty.

• To create the appearance of decisive action, the health minister sets up some sort of body with an impressive title to oversee the mostly doomed recommendations of the report (or perhaps to put some distance between the minister and the sector). She or he throws a bit of money at whichever stakeholder group is shouting the loudest and hopes for the best. By this time the government is near the end of its term and the minister is secretly gunning for a promotion to Treasury, or at least a portfolio where the issues are more straightforward and the stakeholders less toxic.

• If the government wins a second term, the minister of the day realises that mental health is a political road to nowhere. She or he gives up on the idea of systemic reform and decides that the best strategy is to keep a low profile and focus on keeping the most powerful stakeholder groups onside so they don’t make trouble leading up to the next election.

• Three years later, after a change of government, a new health minister arrives, recognises the urgent need to do something about the dire state of mental health, becomes confused by the lack of clear policy direction and stakeholder in-fighting, and sets up an inquiry…

And so the cycle continues, as it has many times over the past thirty years, both federally and in the states. Meanwhile, Australia spends more than ever on mental health services with no sign that outcomes are improving. A staggering one in eight Australians are now taking antidepressant medication (the second-highest rate in the OECD) and our age-standardised suicide rate has increased by 13 per cent over the past decade.

One way to read the Productivity Commission’s report is to treat it as a comprehensive record of the mental health system’s failure to fix policy and service-delivery flaws we’ve known about for decades.

Twenty-seven years after the release of the Burdekin report on the human rights of people suffering mental illness, hospitals and correctional facilities are still routinely discharging people with mental illness into homelessness.

Twenty years after the publication of the first National Suicide Prevention Strategy, half of all people discharged from a hospital after a suicide attempt don’t receive any follow-up.

Fourteen years after a Senate inquiry into a national approach to mental health found that “services have failed to meet the standards Australians should now, after many years of inquiry and reform, be able to expect,” mental health consumers still describe their experience of seeking treatment in hospitals as inefficient, traumatising, inadequate, stigmatising and distressing.

If this latest report somehow defied the odds, we would all be better off. Its conceptualisation of the problems and its recommendations would dramatically improve how mental healthcare is provided across Australia. Its main focuses are worth highlighting:

Robust economic modelling: The report applies a sharp economic lens to mental health. Expenditure of $4.2 billion per year, it concludes, would deliver an annual $18 billion in benefits, mainly from improvements in people’s quality of life, plus a further $1.3 billion each year from increased economic participation and productivity.

Prevention: While prevention is not the report’s focus, the Productivity Commission goes as far as it can within its terms of reference to stress the need for more and better preventive health measures, including actions to reduce trauma in early childhood and tackle workplace stress and bullying.

A broader approach: The need to work across portfolios — including within the justice system, policing, housing, education and income support — is a key thrust of the report.

Shared responsibility: Another strong theme is the importance of distributing responsibility for mental health across the government and non-government sectors, with key roles for workplaces, educational institutions and the business community.

Aboriginal and Torres Strait Islanders: The recognition of the mental health impacts of racism and the emphasis on cultural competence across the mental health sector is a strength of the report. It supports the role of peer workers and makes clear that Aboriginal and Torres Strait Islander people should lead the development and implementation of an Indigenous-specific suicide prevention strategy. It also calls for an implementation plan for the National Strategic Framework for Aboriginal and Torres Strait Islander Peoples’ Mental Health and Social and Emotional Wellbeing 2017–2023, which “was endorsed by the Australian Health Ministers’ Advisory Council and is highly regarded by both Indigenous and non-Indigenous peak bodies.”

Increased consumer focus: All mental health inquiries pay lip service to the importance of consumers and carers, but this report takes a more nuanced approach, recognising the complexity and diversity of these groups and the many ways they can engage with mental health policies, programs and services. It suggests tangible engagement strategies like co-design and co-production and recommends the funding of new national mental health consumer and carer peak bodies.

Technology: New modes for delivering mental healthcare are highlighted as a way of meeting increased demand for treatment by reducing the need for expensive face-to-face services.

The report also recommends structural changes across the system in two areas: accountability and governance. A lack of accountability was the major governance issue raised by participants in the consultation process, it says. The current mechanisms for holding jurisdictions accountable for mental health outcomes are “weak and poorly developed,” with poor integration of consumers and carers, and the absence of a “culture that requires demonstration of program impact and evaluation.”

In discussing the need for better evaluation, the report questions the value of big-spending mental health programs like the recently expanded MBS-funded Better Access program and the youth-targeted Headspace centres.

It also questions the consistency of GPs’ performance in providing mental healthcare. Some GPs do an excellent job, it says, but too many lack knowledge and skills in mental health, and rely too readily on medication as a treatment option. GPs need more competency in “identifying risks, diagnosing conditions, assessing and recognising the physical health consequences of prescribed treatments, and connecting people with other services (including online mental health services, allied health services and non-clinical services such as counsellors).” A “rigorous” evaluation of the Better Access program is “urgently needed.”

In relation to Headspace, the report finds a mismatch between the needs of consumers and the services provided by these centres. “About half of young people presenting at Headspace centres have either mild, moderate or no symptoms of mental ill health,” it says, “and about half have low or moderate distress — indicating that low-intensity services may well be suitable for a many of these young people.” But “among young people with mental ill health who received an assessment, four out of five went on to receive individual therapy (which is not a low-intensity service).”

To improve the performance of mental health programs and policies across the board, the report argues for a “culture of evaluation.” It recommends that the National Mental Health Commission should drive the dissemination of this culture, on the basis that it already has a mandate to work across all areas with an impact on mental health and that the cost of expanding its role would be lower than establishing a new body. To strengthen the independence of the NMHC, the report recommends making it a statutory authority.

In relation to governance, the report argues that “the scale and complexity of many mental health policy issues has thus far exceeded the design of national committee structures.” Distortionary and unclear funding arrangements are undermining the efficient use of resources and causing an overreliance on Medicare-funded and hospital-based services.

As well as recommending a new whole-of-government National Mental Health Strategy, the report recommends that federal, state and territory governments establish a Special Purpose Mental Health Council to facilitate mental health reforms across health and non-health portfolios. It suggests several strategies to improve cooperation between Primary Health Networks and Local Hospital Networks, including a requirement for comprehensive joint regional planning and formalised consumer and carer involvement, to be overseen by the NMHC. If that doesn’t work, the report recommends a more radical approach involving new Regional Commissioning Authorities to pool and administer the networks’ mental health funds.

As I said, these are all excellent ideas. But the question remains: does the current government have the appetite for what are major structural changes?

Based on previous form, it is unlikely that Scott Morrison and his colleagues will take on the report’s bolder cross-sectoral recommendations. As Nicole MacKee points out in Croakey, recent government actions — including the $1.2 billion settlement of the robodebt case and the vote by Australia’s attorneys-general for the age of criminal responsibility to remain at ten, despite a 2019 United Nations Committee on the Rights of the Child recommendation of fourteen — demonstrate a lack of commitment to recognising the mental health effects of decisions made in other portfolios.

But the government might be willing to consider some of the more narrowly focused recommendations, and even to allocate significant funding if it is confident of success, both practically and politically.

The prime minister has committed to responding to the report in next year’s pre-election budget. With big spending measures needed to drag Australia out of a Covid-induced recession, some serious mental health funding could be on the agenda. But there is also a risk that this opportunity will be wasted and the fruitless cycle of failed reform attempts will continue.

It’s easy to point the finger solely at governments, and of course successive governments at all levels could and should have done more. But the mental health sector, particularly the providers of mental healthcare, also bears some responsibility for the repeated failures in this area. It’s hard for any government, no matter how committed, to make progress in a policy area in which the stakeholders are divided, disorganised and antagonistic and put their own interests above those of the sector as a whole.

This report and next year’s budget provide the best chance for decades to break the cycle. With budget priorities for 2021–22 likely to be locked in around March next year, the sector has only three months to take advantage of the opportunity. Only if it comes together to agree on key priority areas, acknowledges the limitations of current programs and services, stops the in-fighting (or at least keeps it behind closed doors), and gives government a realistic plan for reform (and commits to backing it if the budget delivers most of the plan) is there a genuine chance to achieve generational change in mental health.

If not, then the government’s only realistic option will be to make a tokenistic response to the report, set up another body with inadequate funding and insufficient support, and hunker down until a new health minister starts the doomed mental health reform cycle again. •

The post Thirty years, and counting appeared first on Inside Story.

By the late eighteenth century smallpox was still extending its global sway. It appeared for the first time along the Pacific coast of North America in the early 1780s and around Sydney Cove in 1789, with a devastating impact on Indigenous peoples. Almost a decade after the first Australian infection, Edward Jenner, an English country doctor, published his Inquiry into the Variolae Vaccinae Known as the Cow Pox, in which he presented evidence that infection with cowpox — a rare pustular affliction on the udders of dairy cattle, and occasionally on the hands of dairy workers — provided protection against smallpox. Henceforth, he argued, cowpox should be used to vaccinate against smallpox.

Until that point, smallpox lymph had been applied under the skin of the arm in the hope of achieving a mild infection. Since it involved communicating the virus itself, the procedure posed some risk to the patient; and because the patient became infective, it also posed a significant risk to the community. It’s even possible that smallpox matter brought to Sydney Cove by British surgeons on the First Fleet for inoculation purposes may have been the source of the epidemic in 1789. Cowpox infection, by contrast, was a very mild affliction and couldn’t easily be communicated.

Jenner promoted cowpox inoculation by making vaccine matter freely and widely available. Even for him, though, securing a supply of vaccine was difficult. Cowpox was rare and appeared only sporadically, and his preference was not to use cowpox directly from the cow but from a human subject who had been accidentally infected or inoculated with the disease. He would then dry some of the cowpox lymph for future use.

But dried cowpox had a much shorter shelf life than dried smallpox, and for almost a year after his Inquiry was published Jenner had no cowpox to use in his own experiments or to send to colleagues. After the discovery of cowpox in a dairy in London, though, two physicians in the city ran inoculation trials and corroborated Jenner’s findings. In spring 1799, they began distributing samples of dried cowpox through medical networks in Britain and further afield, though initially few samples proved effective. During 1800, greater care in storing and packaging lymph made possible the establishment of the practice not only in parts of western Europe but also in Boston, Massachusetts.

Jenner’s practice of using cowpox from the vesicle, or blistering, of a vaccinated child to inoculate another batch of children pointed to another way of transporting the vaccine. It became common for a country doctor to first take a child to a town where innoculation was available, and then, on returning home, draw fresh lymph from the vaccinated child to inoculate others. This method of arm-to-arm transmission was used in summer 1800 to deliver vaccine to the Royal Navy in the Mediterranean and to introduce the vaccine in Malta, Sicily and southern Italy.

These successes stimulated interest in making vaccine available throughout the British empire. From 1800 on, many samples were sent to India, but none survived the voyage through the tropics. Jenner put forward a plan by which children on board ship were successively vaccinated to keep up a fresh supply of vaccine. All that was needed, he claimed, was an experienced vaccinator and ten non-immune children. A plan of this sort was approved early in 1803, only to be rendered redundant by reports that vaccine sent overland was in service in India.

The year before, two thirteen-year-old boys born in New South Wales, John Cresswell and John Norton, had played their part in its passage through India. When a ship bound from Sydney to Calcutta, the capital of British India, called in at Madras, Dr James Anderson, the chief physician there, organised Creswell’s vaccination from an Indian boy and then arranged with the ship’s surgeon to vaccinate, at intervals, two Malay sailors and John Norton, who became the source for the beginnings of vaccination in Calcutta.

Samples of vaccine were probably sent to Australia at every opportunity. In 1800, Philip Gidley King, the newly appointed governor of New South Wales, was certainly interested in smallpox prophylaxis. He had first gone out to Australia in 1788 and, as lieutenant-governor of Norfolk Island, had written in 1791 asking Sir Joseph Banks to send smallpox matter to inoculate the children in the colony. After returning to England with a young family in 1796, he evidently took interest in Jenner’s discovery; setting out for Sydney again, he may well have taken some vaccine with him, though if he did, nothing came of it. Back in the colony, he organised an inspection of the local cattle in the hope of finding cowpox.

Not long after, in London, John Savage and William I’Anson, who were going out to Australia as surgeons, made it their business to gain experience in vaccination. Setting out on HMS Glatton early in 1802, Savage made sure he had a supply of fresh vaccine and may have secured approval to seek to maintain it on board by successive vaccinations. Once at sea, he was frustrated by the ship’s surgeon’s refusal to assist his plan and the captain’s unwillingness to “take the responsibility on himself” to intervene. After seven months at sea, his vaccine proved inert on arrival.

Governor King was increasingly concerned by smallpox’s potential impact on the “the rising offspring of the inhabitants” but also aware of the challenges in securing live vaccine. In a dispatch in May 1803, he requested that vaccine be “sent out in every possible way by a whaler,” observing that such a vessel’s voyage “will not be more than four months, which may ensure its efficacy.”

By this stage, there was even the possibility that Australia might be supplied from India. Having managed to send viable vaccine from Madras to Sumatra early in 1803, Dr Anderson recruited Indian mothers to accompany vaccinated children to Prince of Wales Island (Penang) and then dispatched samples to Sydney. In a letter to Anderson in May 1804, William Paterson, lieutenant-governor of New South Wales, expressed appreciation for his efforts in a cause so important to “the welfare and happiness of this infant colony.”

John Shoolbred, the superintendent of vaccination in Bengal, likewise drew up plans to use children from the Orphan School to carry vaccine to Penang and potentially on to the East India Company base in Canton. Aware of the needs of New South Wales, where “all attempts to introduce it had hitherto failed,” India’s governor-general, Richard Wellesley, asked him to consider the feasibility of delivering vaccine there. Having looked at the logistics, Shoolbred advised that the voyage of ten weeks or more would require more children than were available. Although vaccination could be suspended in the Orphan School until “a sufficient number [of children] shall accumulate for the purpose,” he counselled against such a move “lest the natural smallpox should make its appearance” in the interim. He assured Wellesley of his continuing efforts to deliver viable vaccine to Sydney via parcels “preserved in different ways.”

The arrival of Coromandel from England on 4 May 1804, after only 154 days at sea, raised hopes. It brought vaccine supplied by both the London Cow-Pock Institution and the recently established Royal Jennerian Society. On the ship’s arrival in Sydney, the vaccine was immediately put to use on susceptible soldiers and orphans. The Sydney Gazette provided an upbeat report of the trials and the government’s plan to make vaccination publicly available, reprinting the Royal Jennerian Society’s promotional material.

By this time, however, it was becoming evident that the samples sent to the government had failed. Sitting down to write a dispatch to Lord Hobart, Governor King expressed his disappointment with the latest failure, proposed that vaccine be maintained on the next voyage by vaccinating the “healthiest prisoners or children on the passage,” and recommended specific direction to the ship’s captain to assist the process and reward for the surgeon as “an incentive to his exertions.”

But Governor King heard good news before he sent his dispatch. In addition to the official consignment, John Ring, a leading vaccinator in London, had sent John Savage a sample of vaccine “put up in a different manner.” A little furtively, Savage used the sample on a child at Parramatta and succeeded in stimulating a vaccine response. After examining the child, Chief Surgeon Jamison confirmed the propagation of the “true vaccine pock” in the colony.

With a supply of vaccine to hand, Jamison and Savage worked to embed the practice. In the Gazette in June, they reported on the successful trials, offered free vaccination, and urged parents to embrace “so great a blessing” for their children. By August, though, with some 400 children having undergone the procedure, it was evidently becoming harder to find volunteers.

In October, Jamison penned his “General Observations on the Small-pox” — the first article on a medical topic published in Australia — in which he challenged the popular perception that “little danger is to be apprehended from [smallpox] in this climate,” affirmed the safety and effectiveness of the new prophylaxis, and expressed his concern that the “vaccine infection” would be lost if people did not avail themselves of it. “Any objection to so innocent an operation in which the very existence of our children is deeply interested,” the editor of the Gazette solemnly added, “must hereafter be considered as a flimsy absurdity.” It was evident to all that maintaining a supply of vaccine would require general and systematic practice.

By early 1805, the tally of vaccinated children had advanced only to 459. In an attempt to extend the practice more broadly, Jamison organised a vaccination tour in the colony, identifying “convenient places of attendance” where the procedure could be performed.

By this time, Governor King had organised the dispatch of vaccine to Norfolk Island and Van Diemen’s Land. The first samples sent to Hobart failed. According to lieutenant-governor David Collins, the failure “must have been occasioned by the weakness of the virus alone,” as Surgeon I’Anson “had particularly attended to the practice of inoculating for the cowpox prior to his departure from England.” In the event, the introduction of vaccination to Norfolk Island and Van Diemen’s Land was achieved by transporting children under vaccination.

Lieutenant Davis used his own children to bring cowpox “live” to Norfolk Island in 1805, and Surgeon McMillan subsequently organised a vaccination chain aboard Buffalo to deliver it to Van Diemen’s Land. McMillan was rewarded, appropriately enough, with a grant of two cows from the public stock. On 19 December 1805, I’Anson was able to report that four boys and a girl had been successfully vaccinated in Hobart, and that two other girls were undergoing the procedure. Among the vaccinees was Robert Hobart May, an Aboriginal boy who had been found at Risdon Cove after British soldiers had fired indiscriminately on his people.

The history of vaccination in Australia after 1804–05 was somewhat anticlimactic. At a little over 10,000, the population of New South Wales was small. Most of the settlers and convicts were smallpox survivors. Many parents were not disposed to have their children vaccinated. In January 1806, Surgeon Jamison made a last bid for their cooperation, warning that otherwise the “vaccine virus must inevitably be lost.” He had “used every persuasion and exertion” to establish “such a laudable system,” he said, and trusted that, “should all the evils I have pointed out occur one day,” “the public” would agree that “no reprehensibility can attach to me.” Stock from vaccine brought on Coromandel was lost shortly afterwards.

Three years later, in October 1809, Lieutenant-Governor Paterson secured a new supply, probably from India. In reporting his successful use of this vaccine, Surgeon Redfern stressed the need “to impress on the minds of the poorer orders of people, whose ignorance renders them but too susceptible of the grossest and most unfounded prejudices, the usefulness, safety, and superior advantages of this new plan of inoculation.” He also suggested the local supply of vaccine could be best secured “by inoculating but a few at a time.” The vaccine was once again lost from the lack of subjects to vaccinate. In 1818, a new supply was obtained from Mauritius and Cape Colony.

In the first quarter of the nineteenth century, several million people were vaccinated worldwide. In some places smallpox seemed to be effectively suppressed. In Australia, the disease appeared a relatively remote threat. Alarms were raised when ships arrived with recent smallpox cases on board, and smallpox-like diseases circulated among the Aboriginal population around 1830, whose source was unknown, but the relative isolation of Australia and the use of quarantine measures provided adequate security in the first half of the nineteenth century.

In this context, it is not wholly surprising that there was some neglect of vaccination except in anticipation of foreign travel. The challenge for the community was that the supply of vaccine and the capacity to respond to sudden demand during an epidemic depended on the routine vaccination of a good number of children. The Vaccination Act of 1853, which made vaccination compulsory in Britain, while formally adopted in some of the colonies, was not enforced. A smallpox outbreak in Victoria in 1857 encouraged legislative measures that had more teeth, but despite more serious scares in Sydney, the practice was never made mandatory in New South Wales.

A serious epidemic in 1881 was a call to action, with public health authorities making provision for large-scale vaccination and strengthening containment measures. Refrigeration and the use of glycerine to store vaccine made Australia less dependent on routine vaccination locally. A great deal of vaccine was imported from Britain.

Overall, the world’s first vaccine was a success story. As the understanding of microbial infection advanced from the late nineteenth century, vaccination against smallpox provided the inspiration for the development of vaccines for other diseases. In honour of Jenner and cowpox, Louis Pasteur proposed using the terms “vaccine” and “vaccination” for all interventions of this sort. Despite popular apathy and a loud anti-vaccination lobby, the practice remained in good repute. Although it was found that vaccination didn’t provide lifelong immunity, it almost always moderated the severity of the disease, and revaccination was advised.

By the early twentieth century, smallpox was largely under control in the Western world, making its last appearance in Australia in 1938. Still, global eradication appeared a distant prospect. In the middle decades of the twentieth century, the number of smallpox cases surged in Asia and Africa; in the 1950s, deaths from smallpox were still counted in millions. Although the means of preventing smallpox had been made freely available for over a century and a half, it took a massive commitment of resources by the World Health Organization, the energy and resolve of local agencies, and immense popular mobilisation to make possible the global eradication in 1979. •

The post Arm-to-arm combat appeared first on Inside Story.

We need to bear in mind one striking characteristic of this virus: it spreads in clusters. Between 10 and 20 per cent of cases are believed to be responsible for 80 per cent of infections via “superspreader” events. These happen when a symptomatic person with a high viral load is coughing, sneezing or talking loudly in a group of people in a poorly ventilated environment. By contrast, most infected people don’t pass on the virus at all.

Of the key metrics epidemiologists employ to describe an epidemic, the one most commonly cited is the effective reproduction number, or R. As we all know by now, this number captures how many new people each case infects on average, and roughly corresponds to the relationship between the number of new cases today and the number we had one incubation period ago (the five to six days it takes for a person to become infected following exposure). A reproduction number of one means that each case infects one other person on average; above one, the outbreak will take off exponentially.

Uncontrolled, the R value for this coronavirus is somewhere between two and three, depending on the setting, which means the caseload more than doubles each five to six days. Once you have 200 cases, you will quickly get to 400 and then 800 within the space of just ten days. Get R below one, and the outbreak peters out.

We reduce R by putting in place interventions including the individual precautions of distancing, hygiene and masks, as well as population-level restrictions such as closing hospitality venues, retail outlets and other services deemed non-essential. Generally the advice on lockdowns is to go early and go hard; four to six weeks covers up to eight average incubation periods, and is seen as sufficient to close down community transmission while testing facilities are moved to surge capacity and workplaces prepare to operate in Covid-safe ways. Shorter, stricter lockdowns can work as circuit-breakers in established outbreaks when transmission rates have started to creep higher.

As a measure of the epidemic, the R number has the drawback of being an average. We now know that the number of cases one person infects can vary from zero to one hundred or more, but we also know that an average doesn’t tell the full story. So we use another metric as well: the dispersion factor, or k. This figure has not been routinely reported in Australia, but it is important for Covid-19 because it describes how much a disease clusters. The lower the k value, the smaller the proportion of cases responsible for transmissions. Flu, for example, has a higher k value than SARS-CoV-2 (the virus responsible for Covid-19) and spreads more evenly through the population if people aren’t immune. SARS and MERS outbreaks, also caused by coronaviruses, featured cluster transmission and in fact had even lower k numbers — and hence greater clustering — than the virus responsible for the current pandemic.

Like the reproduction number, k depends on local population characteristics (demographics, population density, number and size of high-risk transmission settings) and the interventions made by health authorities and governments. We didn’t know all this at the start of the pandemic, and the clustering transmission only became dramatically evident in wave two.

The beginning of Victoria’s second wave was buried in the tail of the first wave. Some of the new cases came as no surprise — authorities were still wrapping up the Cedar Meats outbreak, after all, and small numbers were continuing to appear, with the odd, refreshing zero-case day.

Health authorities didn’t test for community transmission in the first wave because they were anxious to focus testing capacity on high-risk returned travellers and their close contacts. But the serious cases that did appear in hospitals — the tip of the iceberg that was community transmission — made it clear there was a problem.

We may never know the true size of the first wave. Mercifully, though, with the big testing blitz in April failing to detect many more cases, we knew the lockdown worked. With measured steps, we managed to open up, having successfully eliminated all the community transmission caused by the first wave.

What’s critical about the hotel breach that sparked Victoria’s second wave is that a significant number of staff and guards were infected in quick succession, taking the virus home and into well-connected communities just as the government was easing the first-wave restrictions. In the third week of June, five additional hotel staff cases were reported in one day, a figure that doubled to ten and then to twenty in a single week, just as the second step out of restrictions commenced. The following week, total cases hit sixty a day; late the week after, 288 were recorded on one day.

Because authorities were increasingly testing symptomatic people (surveys suggest about half of Victorians with symptoms seek testing), this resurgence provided the data to build a more complete picture of the outbreak. We also gained a better understanding of transmission, with the sum of global evidence to date confirming that it mostly occurs via the respiratory route from droplets or, less frequently, aerosols. The evidence was also confirming that transmission usually occurs in clusters, most often when people are in close proximity indoors, with poor ventilation, for extended periods.

Melbourne’s second wave took off quickly because of the early superspreading, which also rapidly introduced the virus into a series of aged care facilities. The devastating acceleration of transmission in workplaces spread back into the workers’ homes and across workplaces or residential facilities. It’s likely that the early lockdown in the first wave prevented this, but it happened so quickly in the second wave — probably because of the demographics of those first local cases among hotel workers — that by the time the second lockdown took effect in wave two, it was too late.

Some commentators began arguing that Australia had opened too soon after wave one and that the resurgence in Victoria was evidence of a “failed suppression strategy.” This no doubt helped erode the public’s faith in the state government’s stage three lockdowns. This was one of the important lessons Victoria could have taken from wave one: that stage three for six weeks is effective in our setting, especially with the addition of masks. This insight was obscured by the unfolding story of what went wrong in hotel quarantine.

Despite the stage three restrictions having flattened the curve for a second time, and the addition of mandatory masks helping push the effective reproduction number below one, stage four was introduced just sixteen days later. Melbourne had already recorded 723 new cases in a single day, and a lack of confidence in stage three and an increasing concern about compliance pushed the setting to the next level of strict restrictions.

With lockdown tightening, and a night-time curfew added to very strict rules about how far and for how long individuals could travel from home, attention focused on the healthcare system’s capacity, and particularly the effectiveness of the contact-tracing process. Reassurances that it had sufficient capacity were countered by regular reports of clear failures. The concern was rising that lockdown would go on for much longer if the public health response was not up to the challenge.

Another sign that the authorities were losing control was the reversion to the most basic views about viral spread. Rather than a nuanced account drawn from the state’s experience and evidence from around the world, the premier’s daily press conferences increasingly focused on the “deadly,” “wildly infectious” virus rather than on the improving response.

Stage four added a series of time and distance constraints on leaving home, targeting the “aggregate movement” the government was starting to cite as the main indicator of risk. Rather than relying on people to follow straightforward rules — work from home, be conscious of the number of close contacts, don’t have visitors at home, take personal precautions and so on, all of which worked in pre-mask wave one — the second-wave restrictions were detailed and complicated.

In the process, an increasing number of the restrictions couldn’t clearly be explained in terms of risk or Covid-19 epidemiology. The curfew was one famous example, but other decisions also sought to micromanage behaviour in seemingly conflicting ways. Cricket nets could be used, for instance, but not tennis courts; a clinical Pilates class couldn’t be run with one instructor and three participants, but in the same space up to five clients could have sessions at the one time, each with his or her own instructor.

By step two of the second-wave restrictions, Melburnians could meet in groups of up to five people from two households in public, as long as they met within five kilometres of home. Many households had to split and take only a subgroup, but of course they then returned to their homes. Epidemiologists would be concerned about the number of households in a potential transmission network, not the number of people meeting in the park. On top of that, premier Daniel Andrews added that the rule was not restricted to the same household over time, effectively placing no limit on the households with which you could connect day to day, though this is where the potential for community transmission lay. Rules that could easily be enforced seemed to trump epidemiology.

When authorities start being prescriptive rather than providing high-level advice and broad principles, they confuse people and are then pressured into making even more specific rules to try to clarify the situation. Rules beget rules. People wait to be told exactly what they can and can’t do. They lose agency, and the government loses engagement.

Strict rules and large fines tied to enforcement also reinforce fear. People get the message that the second wave is somehow different, more “wildly infectious” than the first. They see neighbouring New South Wales managing to combat community transmission without restrictions and wonder how Victorians could be in this situation.

The coronavirus found the state’s capacities to be wanting in many respects. The health department had been pared back so severely that its starting point was behind those of other states. More importantly, though, the health authorities seemed to lack the capacity for the detailed analysis needed to inform and evaluate the components of the lockdown as it was unfolding.

Modelling was a feature of the “science” behind Victoria’s response, but it was communicated in a way that failed to instil confidence. The questions asked of the modellers focused on the implications of opening up further than the government was planning, and the high risk of a resurgence was then used to argue for stricter or longer restrictions. The time modelling was used to good effect, in my view, was when it evaluated risk among schoolchildren and led to an earlier-than-planned staged return to the classroom.

The aged care sector was not only woefully unprepared for the second wave, but authorities also took a long time to face up to fundamental challenges of workforce training, movement between facilities, and resident management. Lockdown played out in a different way in these settings, with many elderly residents confined to rooms and denied family access for extended periods. Aged care shortcomings were highlighted early in the second wave by both the unacceptable death toll and testimony to the royal commission into the sector. The case numbers, and especially the deaths, fed into the pressure for lockdown.

With part of the population now extremely concerned about the virus and/or our ability to contain it, and others unconvinced about the rationale behind the rules, public discussion — as opposed to assertion — largely closed down. The lockdown was politicised to a point where questioning any of the decisions, or the “science” behind them, could be met with threats of violence against the expert or journalist. In fact, divisiveness featured in the rules themselves, and was dominant in Premier Andrews’s commentary at his daily press conferences.

The five-kilometre rule and the “ring of steel” around Melbourne divided families, and divided customers and tourists from businesses and accommodation. Some services were unable to reopen because too many of their clients lived beyond the “ring” or outside a five-kilometre radius. Those on Melbourne’s fringes had fewer services within their five kilometres; a lucky few had a beach. Support services could open in step two, with indoor groups of up to twenty, but in regional Victoria twenty people could dine indoors at a restaurant while religious meeting places were closed and only ten could attend a prayer service outdoors. The former figure has now increased to forty, but the indoor–outdoor divide remains.

Importantly, some decisions ultimately determined which businesses and industries would survive. The loudest voices from different sectors can have more influence when the grounds for deciding what is and is not allowed become more fine-grained and arbitrary.

Regional Victorians were praised for their good behaviour and promised rewards. They were “fiercely protective” of their low-risk status, Melburnians were told, and didn’t want the metropolitan area opened because of the virus risk, even when case numbers fell to very low figures. As Melbourne was poised for step three, regional Victoria — which had already been granted additional leniency under step three — opened further; instead of returning to one state, the ring of steel was reinforced.

It will be a long time before we can see all the consequences of these extraordinary restrictions, much less measure them. The data collected on all 20,000 cases will provide rich evidence of transmission patterns, the effectiveness of different components of lockdown, and those mystery cases whose risk profiles we may be able to glean from the data.

Most of the information has been gathered via lengthy interviews with cases, which only moved from hard copy to direct computer entry surprisingly late in the piece. Artificial intelligence is now being employed to extract information from the data, but ideally this would be done at the time of interview for key exposures so that the epidemic dynamics could be monitored in real time and public health responses tailored appropriately.

Blanket restrictions were right for the first wave when we were still learning about this virus, its transmission routes and the consequences of infection. Somehow Victoria took a path that led to an even blunter set of restrictions in the second wave, and they didn’t work nearly as fast or as well. Public health benefits must always be weighed against the wider costs to health, economy and society.

In the end, the very failings of the second lockdown were used to justify more of the same. My main concern with these latest restrictions is that by September, with case numbers in low double digits, this lockdown was essentially being used to suppress transmission risk in the wider metro community so that, if public health responses failed, the collateral damage would be minimised.

By October, the health department had adopted the “contacts of contacts” approach to outbreak control that I had been advocating for months. Along with renewed efforts to find sources, which are critical in superspreader epidemics, rapid and comprehensive contact tracing promised to limit cases and end outbreaks sooner. In essence, it brings lockdown to the virus itself by asking all contacts of cases, and all of their contacts, to isolate until tests are completed and the extent of spread is determined. The second ring of contacts, if infected, are thus likely to be in isolation before they are even infectious, a game changer that removes the need for heavy state- or city-wide restrictions.

The biggest lesson from Victoria’s second lockdown is that everything must be done to prevent the need for another. We will no doubt see more cases, even if we get down to zero now. But the upgraded public health response we are told is in place — early-warning systems, workplace screening, sentinel surveillance, increased testing capacity, and a ramped-up, localised public health response — should prevent further waves and restrictions. Nonetheless, we must interrogate what happened, what we did well, and where there was more cost than benefit.

The final lessons of lockdown will be in the opening up. So far, the government’s extreme caution suggests a great fear of relying on the new system in the absence of strict lockdown. I trust this is a story of too much caution from our leaders rather than of concerns about the state’s capacity. •

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

The post Lessons from the lockdown 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.

Victoria’s caseload — and hence its risk to other states — has fallen sharply; so how long will New South Wales and South Australia take to reopen to Victorians? And when will Queensland, Western Australia, Tasmania and the Northern Territory reopen to the rest of Australia?

Finally, when will we enter the long-awaited “travel bubble,” opening our borders to flights from other countries deemed Covid-safe, and their borders to quarantine-free travel from here? Will the New Zealand election on 17 October clear the way for negotiations to start reopening the skies?

Three government-imposed barriers — the lockdown of Melbourne, the closure of most interstate borders, and the ban on travel to and from Australia (with exceptions) — must be lifted before the economy is likely to come out of its deep recession, which has so far cut Australia’s output by 7.25 per cent and left almost two million Australians unemployed or underemployed.

Lifting the barriers will not be enough to bring about a full recovery. Consumers and investors are likely to remain cautious until a successful global vaccine rollout removes the virus as a key factor in the way we live, or until we learn a way to live with the virus. Whichever it is, that could still be a long way off.

And, on current plans, it could still be quite some time before life in Victoria returns to anything like normal. Despite its plunging caseload, Melbourne faces another four weeks of curfew and lockdown. And there is not a single country, other than remote islands, that meets the threshold set by the Andrews government for the next easing of restrictions — such as allowing Victorians to have more than one family visit them at home.

Start with the good news. Melbourne’s rolling fourteen-day average of new cases — which the Andrews government uses to set the benchmark for easing its lockdown and curfew — has already rolled well past official predictions. Indeed, it’s rolled out of the range it was meant to be in for the next tweak of restrictions.

Premier Daniel Andrews’s threshold for the next easing was a city-wide rolling fourteen-day average of between thirty and fifty new cases (as the modellers forecast) by 28 September. Melbourne reached that range twelve days early, on 16 September, and is now rolling out the other side, with an average of 25.1.

The premier has flagged that he will announce a further easing of restrictions “in certain areas” on Sunday — but immediately cautioned that “they have to be cautious steps, steady steps and all the steps we take have to be safe.” In other words, don’t get your hopes up.

(One area he is likely to free from the curfew and lockdown is the Mornington Peninsula. It is the only local government area in Melbourne with no active cases — and it has three marginal seats, and a bunch of hostile voters who say they’re not part of Melbourne and don’t need to be locked down.)

The caseload has fallen so sharply — using the weekly tally of new cases, by 97 per cent from its peak in early August — that the government has ample room to move. But Andrews has flagged that any moves will be only modest; he wants this success to be seen as confirming that the hardline strategy is the right one, and one that Victorians will go on supporting.

While those opposed to the lockdown are growing increasingly angry and frustrated, they are a minority — and for them, the plan Andrews set out on 6 September offers little hope. Melbourne’s lockdown and curfew are to continue until at least 26 October, with only minor modifications to start next Monday: principally allowing another 100,000 workers (about 3 per cent of the total) to go back to work, allowing some students back into school, and reopening childcare.

And before the city can take the next step — returning it to something like the restrictions that applied in June — the rolling average of new cases statewide will have to fall to less than five a day, with no more than five new cases that officials cannot link to a known outbreak.

That’s just over ten new cases per million people in a fortnight. Among developed countries, only Taiwan and New Zealand (just) meet that test; New South Wales would have failed it until this week. It is extreme.

Independent epidemiologists, including the government’s modeller, Professor Tony Blakely of Melbourne University, have challenged the need to set the threshold so low. The infection of just one five-person household would provide a day’s quota; one of them each day for a fortnight would mean the entire city has to stay locked down and in curfew.

If Melbourne were to meet that threshold by 26 October, the curfew would be lifted. People would be free to come and go from their homes, and the five kilometre limit on travel would be removed. But you would still be allowed to invite only members of one nominated family to your home; public gatherings outdoors would be limited to ten people. Weddings and religious ceremonies would also be limited to ten people, with twenty allowed at funerals.

Schools would slowly reopen. Shops would reopen. Restaurants could reopen, but only with predominantly outdoor seating. People must still work from home if they can. Outdoor sport could resume for kids, but only non-contact sport for adults. Accommodation in hotels and motels could reopen, with caps. Entertainment would be allowed at outdoor venues only. It would not be life as we know it in the rest of Australia.

Those rules already apply in regional Victoria, whose 1.5 million people now include just ten active coronavirus cases. All but seven council areas in regional Victoria now have no coronavirus at all, but their residents are still subject to these restrictions, and the fines that come with them.

The threshold for the next step, in Melbourne and regional Victoria alike, is really steep. Victorians won’t be allowed to have visitors from more than one household, or have weddings or services with more than ten people, until the entire state has had no new cases of coronavirus for a fortnight. Until that happens, the third-step restrictions will stay on indefinitely.

Apart from some Pacific islands that have dodged the virus entirely, no country in the world would clear that threshold. None. Even Taiwan, the gold medallist in suppressing the virus, reports several new cases a week. Cambodia claims to have had only two cases in the past month, and Laos one, but some have been unkind enough to question the accuracy of their data.

No mainland states would pass that test. In the past fortnight, even South Australia has reported three new cases, Western Australia nine, Queensland ten, and New South Wales seventy-one. New Zealand has reported thirty-five. Tasmania and the territories haven’t reported any, but they are far smaller than Victoria.

Daniel Andrews and his advisers claim they are not attempting to eliminate the virus from Victoria. In fact the thresholds they set for the final two steps both require that the virus has been eliminated, so that is clearly untrue.

Their real aim seems to be to repeat what New Zealand did in the first wave of the virus: with the country closed down, it had three weeks in May and June with no new cases. But since it reopened, New Zealand has had more than 300 new cases, leading its government to send Auckland back into lockdown for several weeks — a lockdown lifted only after prime minister Jacinda Ardern overruled her health officials to order the city back to work ahead of the 17 October election.

For it is a question of getting the right balance. If a country or state is losing its fight to control the virus, as Western Europe is right now, clearly lockdowns are the best way to bring it under control. But there are many costs to that, as New Zealand can testify, and as Victoria too is seeing.

New Zealand’s statistics agency Stats NZ reports that in the June quarter, while the official unemployment rate was just 4 per cent, Covid-19 restrictions meant that 8 per cent of employees were in fact working no hours at all, while a further 13 per cent were working reduced hours.

The country’s GDP shrank 13.4 per cent in the first half of 2020, almost double the 7.2 per cent fall in Australia. New Zealand’s version of JobKeeper is far more inclusive than Australia’s, so the pain was felt more in business and government than in households. But when demand shrinks so much, businesses fail, people lose their jobs, and the young are the biggest victims.

Victoria is now well down that path. It has a quarter of Australia’s population, but the Australian Bureau of Statistics reports that in the year to August, Victorians lost more paid hours of work than the rest of Australia combined. Victorians suffered almost half the nation’s job losses. And with JobKeeper and JobSeeker shrinking, each week in lockdown puts more pressure on firms and small businesses that are not earning enough money to survive.

The young are suffering the most. In a year, one in four full-time jobs for school leavers have disappeared. Some 105,000 Victorians aged fifteen to twenty-four are no longer in full-time education and have no job at all. We saw in the 1990s that prolonged recessions do permanent damage to the working lives of those who become long-term unemployed. That will happen again this time.

I puzzle over why this is such a low priority for the Andrews government, and for Victorians — particularly those who normally fight for progressive causes. It seems clear that to most of them, there is only one goal: to defeat the virus. And so they support the hard line of lockdowns, curfews and mass unemployment to ensure that it is defeated.

After conflicting polls two weeks ago, a deluge of recent polls has made that clear: from Essential, Newspoll, Roy Morgan, and (if less unexpected) Redbridge, run by Labor’s former deputy campaign director, Kos Samaras.

Together they show that, while the Andrews government’s support has been dented by its mistakes in handling the crisis, its lockdown policy enjoys solid support.

The one negative poll, by MediaReach for the state Liberals and leaked to the Herald-Sun, showed a double-digit landslide swing in four marginal seats to the Liberals. But I suspect we should file that in the same bin as the same pollster’s Northern Territory poll in late June for the Territory Alliance, which claimed the Alliance was evenly poised to win the territory’s August election. In fact it won just 13 per cent of the vote and one seat.

A Morgan poll two weeks ago reported that 70 per cent of Victorians supported the way Daniel Andrews has handled his job. The Australian on Tuesday reported that Newspoll found 61 per cent of Victorians think the premier has handled the epidemic well, and only 36 per cent think he has done it badly. The lockdown garnered slightly less support: 54 per cent of Victorians thought the restrictions “about right,” 6 per cent rated them “too lenient,” while 37 per cent judged them “too strict.”)

The Essential poll in the Guardian reported greater opposition: only 47 per cent of Victorians said their state government had responded well to Covid-19 — whereas in other states voters gave overwhelming support to their government’s response, ranging from 67 per cent in New South Wales to 84 per cent in Western Australia.

Only Morgan asked about voting intentions, and it found quite a swing. It reported that Labor’s support has slumped 6 per cent since the 2018 election — but that was an extraordinary high-water mark, so Labor still had 51.5 per cent of the two-party vote. Polling the regions is very difficult, but for what it’s worth, the poll implied a swing of 8 per cent against Labor in greater Melbourne but just 3 per cent in regional Victoria.

To me, the most telling responses in any poll came when Essential asked Victorians to agree or disagree with a series of statements about the crisis. Asked if “the restrictions affecting my area seem appropriate,” 60 per cent agreed and only 19 per cent disagreed. Just 32 per cent said the restrictions have had much impact on their own lifestyle. And 64 per cent thought the lockdown and curfew would be effective in stopping the spread of the virus.

It’s hard to disagree with that: the restrictions have clearly done the job asked of them. But the gains from reducing the daily average of new cases from 533 to fifteen are far greater than those from trying to reduce it from fifteen to zero, whereas the costs keep mounting at the same rate. At some point soon, the policy balance has to shift.

On border closures, the policy shift has begun, with almost daily announcements. South Australia has opened up to New South Wales and the ACT: only Victorians remain banned. Since the case rate in regional Victoria is now lower than in her own state, Gladys Berejiklian is considering whether to open borders to them. Even Annastacia Palaszczuk has joined in, allowing people from the ACT, Byron Bay and the NSW border region to come and enjoy Queensland.

All premiers except for Western Australia’s Mark McGowan have promised to open their borders by Christmas. WA voters seem to love keeping easterners out, and McGowan faces re-election next March. Queensland’s election is on 31 October; whoever wins, it’s assumed that its borders will open soon after that. The NT election is already out of the way. And well before Christmas on current trends, Victoria’s caseload will be low enough for there to be no reason to exclude it.

Interstate borders, at least in eastern and central Australia, should be open by the start of summer. International borders will take much longer to reopen — much longer.

Globally, the daily numbers of new cases are setting records, running at close to a million new cases every three days. Today’s numbers report 85,919 new cases in India, 43,995 in the United States, and an astonishing 16,096 in France — just before the French Open starts on Monday! Qantas chief Alan Joyce’s once-gloomy forecast that international travel won’t start returning to normal until mid 2021 now looks optimistic.

The idea of setting up a travel bubble among relatively Covid-free countries within our region ought to be a winner. While new case numbers are exploding in Indonesia (4634 yesterday), the Philippines (2180) and Nepal (1497), much of Asia is reporting little new activity. Last week, for example, the growth in the total caseload per million people was zero in China, Taiwan, Vietnam and Papua New Guinea, one in Japan, two in Australia, four in New Zealand and the Maldives, and five in Sri Lanka. Most of the South Pacific remains Covid-free. Why not open the doors to safe neighbours?

Unfortunately, there are lots of reasons why. It might happen with New Zealand, maybe the South Pacific, possibly even Japan. But there are obvious political problems for Australia in negotiating an opening with China in this environment. And if we don’t open up to China — or it refuses to open to us — we risk another Beijing tantrum if we open up to Taiwan.

In other countries, the data can’t be trusted — either because they are doing little testing or because they are hiding the true numbers, or both. Last week Myanmar abruptly bumped up its caseload per million people from forty-four to eighty-two.

And situations change rapidly. Five months ago I wrote about Singapore and South Korea as examples of how to keep the virus under control. Both are still among the best in the developed world, but measured by growth in new cases per capita, South Korea now exceeds Australia, and Singapore exceeds Victoria. Outbreaks can erupt quickly, or spill out of secret cupboards, turning what seemed like a good idea into a threat to our hard-won victory over the virus.

If we are lucky, the debate in 2021 will shift from how to reopen interstate borders to how to reopen international ones: at the very least, for returning Australians, wider family members, skilled workers, students — and Covid-free neighbours. Too much depends on it for the doors to remain shut as now. Test, trace and quarantine has to be our path to the future. •

The post Covid-19: where next? appeared first on Inside Story.

At the other end of the video link, sitting at a single long table in Canberra, are the three most senior Commonwealth officials entrusted with oversight of Australia’s aged care sector: commissioner Janet Anderson, who heads the aged care regulator; Professor Brendan Murphy, secretary of the health department; and Michael Lye, the department’s deputy secretary for ageing and aged care.

Rozen is grilling the panel about evidence presented to the commission earlier that morning suggesting that the federal government failed to plan adequately for Covid-19 outbreaks in aged care. The commission has been examining two documents: the health sector’s emergency response plan — a fifty-six-page document outlining the overall health sector response that only mentions aged care twenty-one times and includes no specific action points or plans for the sector — and the guidelines for individual aged care facilities issued by Communicable Diseases Network Australia, a government body, which the government has repeatedly cited as evidence it had a national plan for aged care.

In excoriating testimony a few hours earlier, gerontologist Professor Joseph Ibrahim had described the CDNA guidelines as a “tick sheet” designed for “some poor bugger sitting in an aged care home, a middle manager,” rather than a national plan. The guidelines themselves repeatedly stress their advisory and non-comprehensive nature, stating that while they “provide guidance on good practice,” they are “not a substitute for advice from other relevant sources,” and that “readers should not rely solely on information contained within this guideline.” They place the onus on planning for Covid-19 squarely on providers, noting that “the primary responsibility of managing Covid-19 outbreaks lies with the [aged care facility], in their responsibility for resident care and infection control.”

Rozen is zeroing in on the fact that the first two versions of the guidelines — released 13 March and 31 April respectively — did not include any federal government role in dealing with outbreaks in aged care. It took a full four months before any Commonwealth responsibilities were added into a third version, on 14 July.

Nonetheless, the two health department witnesses are adamant that a national plan for aged care existed all along, with no lack of clarity about the federal government’s role. Murphy insists that the CDNA guidelines are a “foundational and comprehensive plan.” In his sworn statement, Lye claims that he doesn’t consider there was any “lack of clarity about the roles and responsibilities of approved providers and state and federal government authorities during the response to the Covid-19 pandemic.”

Rozen presses Lye on why the federal government’s responsibilities were not included in the first two iterations of the CDNA guidelines.

Lye demurs.

Rozen presses him again: “I’ll ask you to accept from me that there is no reference at all to the Australian government’s role in relation to aged care in either of the first versions of this document or the second. Does that surprise you?”

Then comes a jaw-dropping moment: Murphy cups his hand over his mouth and whispers the phrase “Australian government document” to Lye.

Lye picks up Murphy’s hint. “Look, it’s our document, counsel, so it’s an Australian government document that deals with aged care,” he tells Rozen. “So it’s possible that in first version that was implicit and then it has been made explicit.”

Embarrassingly for Murphy, the microphone has picked up his whisper.

“Did Professor Murphy just whisper to you the answer he suggest you give, Mr Lye?” Rozen asks.

There’s an excruciating beat of silence.

“I just — I just said it was an Australian government document, which — which it is,” Murphy replies defiantly.

It’s tempting to zero in on the shock value of this moment, and linger there. After all, it’s not every day that a secretary of the department of health is caught coaching a witness at a royal commission. But more astonishing than Murphy’s whispered intervention is the substance of what he was suggesting.

Murphy’s claim was that the federal government’s CDNA guidelines didn’t need to state the government’s role or responsibilities in managing Covid-19 outbreaks in aged care — because the federal government itself produced the document.

For aged care providers, this is a bit like reaching into your seat pocket for the emergency instructions on a plunging aeroplane and finding a card that advises you to come up with your own exit strategy, with no information on what the plane’s crew will do — then being told the crew’s role is implied because the airline printed the card.

The emerging picture of the federal government’s failure to prepare Australia’s residential aged care facilities for Covid outbreaks is so damning, the omissions and errors so comprehensive, that it will likely take years for its full scope to come into view.

What do we know so far? The foundational failure was the fact that the government entirely neglected to take account of the existing shortcomings of the aged care system in considering what response would be required. The existing operating environment in Australian aged care — in which the baseline standard of care is already deficient, and the workforce lacks the skills and the numbers to cope with the needs of the elderly within the system — is not mentioned in either the CDNA guidelines or the overall health sector emergency response plan.

Nor does either document refer to the issues that prompted the royal commission in the first place: chronic understaffing, skills shortages, ineffectual regulation, endemic neglect and basic failures of care, overreliance on chemical and physical restraints, sexual and physical abuse, malnutrition, dehydration, preventable injuries and premature deaths.

The royal commission also heard that the federal government did not consider the specific challenges of infection control in an aged care setting, including the high degree of physical contact and the home-like environment, nor the operational differences between aged care facilities and hospitals, nor the fact that personal care workers — the majority of the aged care workforce, who can have as little as a six-week certificate qualification, or in some cases no qualifications at all — lack the basic awareness of infection control that is taken for granted elsewhere in the health sector. In short, the government did not consider any of the sector’s widely known failings when considering what measures or support it might need during an unprecedented pandemic.

The government also failed to ensure a standardised approach to infection control. It had no mechanism to make high-level infection control expertise available to providers from the outset of an outbreak: at Newmarch House, for instance, where the outbreak claimed nineteen lives, such an expert was only on site after two weeks. The government’s online training in the use of personal protective equipment was voluntary, and as of early June only one-fifth of the workforce had completed it. Face masks were not made compulsory for aged care workers until 13 July, long after scores of residents had died at both Dorothy Henderson Lodge and Newmarch House, and after residents had begun to die of Covid-19 in Victorian aged care facilities.

The government also provided incomplete or incorrect advice to providers, notifying aged care facilities as late as August that they needed to plan only for a loss of up to 30 per cent of their workforce in the case of an outbreak — in spite of Dorothy Henderson Lodge having lost almost its entire workforce within the first forty-eight hours of its outbreak back in the first week of March, and despite overwhelming international evidence that aged care workforces were being decimated in the case of major outbreaks.

Nor had the government established clear channels of communication and responsibility, leading to buck-passing and critical delays in information sharing between various levels of government and the regulator. One result was a four-day delay before the regulator notified the health department of the outbreak at St Basil’s Home for the Aged, which has now claimed forty-four lives, or more than a third of its residents.

Many of the meagre measures the government had put into place were not properly or fully implemented. Unbelievably, as of 21 August the government had spent only half of the $43 million it had allocated for its surge workforce, in spite of widespread reports of residents being left soiled, unfed and without other basic care in affected homes across Victoria. And while it distributed $92 million to aged care providers in a “one worker, one site” scheme to stop staff working at more than one facility and mitigate the spread between facilities, the government admitted it had no way of enforcing the directive or tracking whether it was working.

The federal government also actively resisted simple measures that would improve providers’ capacity to plan for and combat the spread. Despite repeated pleas from providers and peak bodies, the federal government refused to release heat maps of facilities with outbreaks — even confidentially to providers — until September, citing the need both to protect providers from reputational damage and to shield them from intrusive media scrutiny. This decision significantly hampered providers’ ability to control whether casual workers from facilities with known outbreaks were rostered on in their facilities.

Nor, in spite of scores of facilities having experienced uncontrolled spread of Covid-19, has the government created a consistent national protocol for hospital transfers of infected residents to ensure the safety of those who are not infected.

Perhaps even more concerning is the degree of defeatism on display in testimony by government officials: at the Senate select committee on Covid-19, Brendan Murphy framed aged care cases and deaths as a fait accompli, saying that “I don’t think it’s possible in any part of the world to make a facility protected from Covid, no matter how well staff do.” In the same hearing, aged care minister Richard Colbeck declared that “no country has been able to avoid outbreaks in residential aged care which we’re seeing in Australia. Where there’s been widespread community transmission, the reality is that we will continue to see outbreaks in all parts of our community, but we see, tragically, the results that occur in residential aged care.”

As well as indicating a fatalistic acceptance of aged care deaths, these assertions are inaccurate: South Korea has a comparable number of total cases to Australia — some 22,055 cases to Australia’s 26,607, yet has avoided widespread aged care outbreaks or deaths.

If the government’s response has been disastrous, the regulatory response has been no better. The newly amalgamated aged care regulator, the Aged Care Quality and Safety Commission — established in January 2019 — suspended unannounced spot checks of providers in March, leaving the sector essentially without regulation during the time it needed it most.

Worse, it allowed providers to self-assess their own readiness for Covid-19 outbreaks, emailing them a survey that included questions such as “Does the service have an infection control respiratory outbreak plan?” and “Overall, how would you rate the service’s readiness in the event of a Covid-19 outbreak?” Unsurprisingly, 99.5 per cent of Australia’s aged care providers assessed their Covid-19 readiness as either satisfactory (56.8 per cent) or best practice (42.7 per cent) — an assessment that has proven to be catastrophically overconfident. Only 0.5 per cent of aged care providers conceded that improvements were needed.

The regulator did not verify these surveys with in-person visits; instead, commissioner Anderson testified at the royal commission that when the regulator rated an individual aged care provider to be at a “high or very high risk” of a Covid-19 outbreak, it audited these responses through “a rigorously structured” phone call in which, she said, “we asked them the usual questions.” On occasion, she testified, the regulator would also ask providers to submit additional information. It was only in instances of “unmitigated risk” that the regulator undertook a site visit.

Only 2345 of Australia’s 2717 residential aged care providers completed the self-assessment survey. It is unclear how, if at all, the regulator followed up with the other 372.

Even as Victoria’s aged care facilities were swamped with cases in August and the inadequacy of the self-assessment mechanism was being interrogated at the royal commission, Anderson testified that the regulator’s fundamental approach of allowing providers to self-assess would continue. When asked how the regulatory approach had altered in the wake of the self-assessments, she replied that the regulator would be “repeating a self-assessment survey with a different and larger set of questions” in order to give providers “the most detailed opportunity to assess their own level of readiness and then to report back to the regulator.” It wasn’t until August that the regulator commenced an infection-control monitoring program.

Curiously, the regulator issued no sanctions or notices to agree — the most serious regulatory instruments available to it — to Victorian aged care homes between 1 January and 16 July, and it only issued two non-compliance notices in the entire year. Yet since 16 July, when Covid-19 had well and truly begun to spread like wildfire through Victorian aged care homes, it has put twenty sanctions and notices to agree in place in Victoria. Aside from two notices relating to financial malpractice, all of them revealed, among other serious issues, that the facilities were not meeting Quality Standard 3(g): the requirement to minimise infection-related risks. Clearly, leaving assessment of facilities’ preparedness for Covid-19 in the hands of providers was a disastrous misstep.

Would these widespread infection control shortcomings have been uncovered and remedied earlier if the regulator had not allowed providers to self-assess their own readiness for outbreaks, or had not suspended unannounced visits? The regulator’s belated issuance of twenty sanctions and notices to agree since July suggests so. Yet between January and March — crucial months in which Covid-19 was raging through aged care facilities overseas — the regulator only conducted a total of twenty-nine on-site visits among the 766 facilities in Victoria, a mere 3.7 per cent of Victoria’s aged care homes.

In the meantime, with nobody in the federal government or at the regulator helming our aged care response, the aged care sector and its workers were left to fend for themselves.

The federal government’s hands-off approach to the aged care sector during the pandemic is no accident: it is entirely consistent with its existing aged care policy settings and agenda, which privilege the interests of providers over those of vulnerable residents, and which have sought, in various ways — often abetted by providers and lobby groups — to progressively deregulate the sector and reduce governmental oversight. These policy settings are underpinned by the pernicious neoliberal shibboleth that vulnerable aged care recipients are empowered “consumers” who exercise “choice” within a free market, and that bad providers will ultimately be driven out of business by competition rather than regulation.

Beginning with the Howard government’s 1997 Aged Care Act — which removed probity requirements for providers, decoupled federal funding from care provision, and removed the requirement for a registered nurse to be on duty at all times in aged care — privatisation and deregulation have continued apace, significantly blunting the regulator’s power, decreasing public transparency about how Commonwealth aged care funding — now an annual $21.7 billion — is spent, and reducing regulation and oversight.

The 1997 Act and subsequent legislation, including Labor’s 2013 Living Longer Living Better reforms, have transformed Australia’s aged care sector, attracting providers “with a profit-maximisation orientation,” as management academic Marie de la Rama notes, rather than an “orientation to care.” With its stated aim of reducing the “regulatory burden” for providers, the Abbott government’s 2015 Red Tape Reduction Plan further eroded government oversight of the sector: among other objectives, it aimed to “streamline financial requirements for aged care providers” and allow consumers to “self-regulate their own care where appropriate.” Together, the 2016 Aged Care Sector Statement of Principles and Aged Care Roadmap consolidated this free market focus, explicitly identifying a “sustainable, consumer driven and market based system” as the ideal towards which the sector must strive.

In July last year, the forty-four accreditation standards for operators were reduced to a mere eight quality standards, which are now phrased in terms of “consumer outcomes.” Standard 3, for instance, states: “I get personal care, clinical care, or both personal care and clinical care, that is safe and right for me.” Rigorous quantitative standards are repeatedly eschewed in favour of “tailored” care and consumer choice — all of which might make more sense if the consumers in question were not vulnerable, elderly aged care residents, over half of whom suffer from dementia, many more of whom are otherwise incapacitated or physically disabled, and all of whom may fear retribution or neglect if they complain about their care.

Accompanying these meagre, vague quality standards is the newly minted Charter of Aged Care Rights, which supposedly sets out aged care residents’ consumer rights, including the right to be treated with dignity and respect, the right to safe and high-quality care, and the right to have control over and make choices about care, including where the choices involve personal risk. In reality, however, as legal academic Linda Steele and her co-authors have noted, the charter is a “soft rights document, in the sense that it is not enforceable.”

Concerns about the human rights abuses experienced by aged care residents run so deep among human rights scholars that some have suggested that the confinement, segregation, restrictive practices, and physical and social isolation that aged care residents experience rise to the definition of a “place of detention” for the purpose of monitoring for torture under the United Nations Optional Protocol to the Convention against Torture.

Yet the deregulation of the sector has been embraced wholeheartedly by both providers and lobby groups, which have vocally opposed increased oversight and mandatory staffing levels and have had undue influence on the formulation of federal aged care policy. Last year, the national industry group Leading Aged Services Australia, or LASA, even opposed mandatory air conditioning in aged care homes when the government considered including the requirement to provide a “comfortable internal temperature” among its quality standards.

In many cases, industry lobby groups have also contributed to the deskilling of the aged care workforce and the propagation of consumer-oriented rhetoric. In one prominent example, the chief executive of COTA, Ian Yates, advocated “consumer-directed care” and “consumer-centric practice” at the royal commission and asked rhetorically whether “everything that a nurse used to do ha[s] to be done by a nurse?”

The Covid-19 pandemic has exposed the mendacious myth of the “aged care consumer” once and for all. Far from being empowered consumers, aged care residents have been utterly powerless to exercise any agency during the pandemic, at the very time they have been subjected to egregious human rights abuses: sedated, placed on end-of-life medication, and denied the hospital care that all other Australian citizens enjoy. Residents have been left without food or water for hours or days, and left in soiled incontinence pads; many have been denied telephone contact with their families and kept in conditions akin to solitary confinement. When family members have attempted to extract them, they have been barred from leaving the premises. Many have been exposed to a deadly virus by care workers who are in many cases undertrained and lack appropriate PPE, and infectious fellow residents with whom they have been kept in close quarters. They have died alone, without the comfort of family — and in some cases, they have reportedly not received adequate palliative care or pain relief.

These human rights abuses are unfolding against a backdrop of ageist public discourse in which aged care residents’ very right to exist is being debated. Drawing on a long history of senicidal thinking that equates economic productivity with social worth, economists, op-ed writers and other commentators have repeatedly suggested that the elderly’s welfare is not worth the hit to the economy. As the aged care death toll in Victoria approached 500, former prime minister Tony Abbott suggested that governments should ask “how much is a life worth?” and weighed up the merits of making the elderly “as comfortable as possible while nature takes its course.” Prime minister Scott Morrison referred to aged care residents as “pre-palliative,” implying they are inhabitants of what has been called a “liminal zone between life and death” in spite of the fact that the average length of stay in residential aged care is 2.6 years, and many residents stay for longer periods yet.

The ageism extends to those clinicians and public health officials who have overtly argued that aged care residents should not be admitted to hospitals. This attitude was reflected in a decision taken by NSW Health in relation to Newmarch House “not to decant residents into hospitals given the precedent this would set.” Residents are “decanted,” like an inert, inanimate substance, rather than moved — and they certainly do not move of their own will. The deaths of aged care residents have even been described as “learnings” by politicians attempting to reframe human tragedy as an educational opportunity for our political class.

Amid the disempowerment, dehumanisation and degradation of aged care residents during the pandemic, the foundational fantasy of contemporary Australian aged care policy — that the system is a free market full of consumers exercising choice — crumbles into dust.

Left with the unenviable task of explaining why the government has been so deplorably unprepared to combat outbreaks in aged care, Scott Morrison recently abandoned his talking points about having had a “comprehensive” national plan, and gave the crisis a new spin. The outbreaks in Australian aged care were “unforeseeable,” he insisted.

The same notion was repeated by the embattled aged care minister Richard Colbeck in a disastrous appearance at the Senate select committee on Covid-19 during which he was unable to recall the number of aged care residents who had died of the novel coronavirus, nor the number of current infections — and nor even whether he had ever briefed the cabinet about the royal commission’s interim report, Neglect, published in October 2019.

The government’s claim that the virus’s effects in Australian aged care were unforeseeable merits close scrutiny. In doing so, it is important to consider what was known about Covid-19 in aged care internationally, well before the horrifying outbreaks in Victorian residential aged care that had, by 12 September, claimed 563 lives, or 78 per cent of all Covid-19 deaths in the state.

In Washington in late February, a Kirkland nursing home, Life Care Center, made international headlines as the first Covid-19 outbreak in aged care; ultimately, two-thirds of its residents contracted the virus, and thirty-seven died. On 10 March, eighteen residents of a single nursing home were found dead in Italy. By 18 March, Belgium had called Médecins Sans Frontières into its nursing homes, where they found staff, without protective equipment, showing the signs of trauma common in disaster zones. A week later, Spain’s defence secretary, Margarita Robles, reported that soldiers sent to disinfect nursing homes had found residents abandoned and dead in their beds.

The following month, in early April, researchers from the London School of Economics International Long-Term Care Policy Network had found that 50 per cent of all Covid-19 deaths in Europe were occurring in aged care homes. On 16 April, it was reported that in the Résidence Herron in Montreal, residents were found listless, dehydrated and unfed for days, with “excrement seeping out of their diapers.” That same week, Canada’s chief public health official, Dr Theresa Tam, noted that approximately half of Canada’s Covid-19 deaths — at that stage, 1193 people — were occurring in long-term care homes.

At the same time, in the United States, seventeen bodies were found in bags in a nursing home in New Jersey after an anonymous tip to police, and analysis published in the New York Times noted that the virus had taken an aggressive hold in nursing homes, where “a combination of factors — an ageing or frail population, chronic understaffing, shortages of protective gear and constant physical contact between workers and residents — has hastened its spread.” By the end of April, it was known that in Spain alone there had been more than 16,000 Covid-19 deaths in aged care homes.

By mid May, it was clear that Covid-19 had killed more than 29,100 aged care residents and staff in the United States, and 13,964 aged care residents in Britain. By 17 May, it was known that 90 per cent of the deaths in Sweden were among the elderly, and half of those were in aged care homes. By 12 June, 19,394 Covid-19 deaths had been recorded in British aged care. By mid June, American aged care deaths had reached 50,000. By early July, official estimates from Spain suggested that 18,830 aged care residents had died from Covid-19.

All of these reports were in the public domain long before the outbreaks in Victorian aged care.

But the government did not even need to look at that overwhelming international evidence to ascertain the scale of the threat. It could have seized on the evidence from two early local outbreaks in aged care: the outbreak at Dorothy Henderson Lodge, which commenced on 3 March and lasted until early May, resulting in the deaths of six residents of the sixteen infected; and the disastrous outbreak at Newmarch House, which commenced on 11 April with a staff member testing positive and ultimately resulted in twenty deaths among thirty-seven infected residents.

An independent review of the Dorothy Henderson outbreak by Professor Lyn Gilbert, delivered to the government back in April, warned the government that “spread of Covid-19 is very difficult to control in a household-like residential setting, with highly vulnerable residents” and that the “major challenge” was “maintaining adequate staffing.”

An independent review of the Newmarch House outbreak, commissioned by the health department and led by Professor Gilbert and Adjunct Professor Alan Lilly, found that the response was bedevilled by problems: interagency confusion; a lack of clarity about the hierarchies among government health agencies; “severely depleted” staffing; significant shortcomings with infection prevention and control; and “compromised” implementation of Hospital in the Home because of “inadequate staffing and support,” resulting in a failure to “provide care equivalent to that of inpatient hospital care.” All of these issues have recurred during the Victorian outbreaks.

“The human imagination does not do very well with large numbers,” Robert Hass wrote in a poem grappling with the monumental death toll of the Korean war. Individual instances of suffering are often easier to grasp than the big picture, he suggests; suffering on a mass scale often overwhelms us.

And it’s true that the scale of the global tragedy unfolding in aged care nearly defies comprehension. In the United States, where nursing home residents make up less than 1 per cent of the population, the current tally of Covid-19 deaths in aged care is a harrowing 77,018 — 42 per cent of the country’s total Covid-19 deaths. In Britain, where collection of Covid-19 aged care data is patchy and deaths significantly underreported, in excess of 30,000 aged care deaths had been recorded as of 12 June, with two-thirds attributed to Covid-19 and the remaining 10,000 yet to be confirmed; that country’s aged care deaths are presently estimated to comprise around 40 per cent of all Covid-19 deaths.

In Australia, aged care residents now represent 74 per cent of all Covid-19 deaths, a vastly higher proportion than most other developed nations. When confronted with this statistic at the Senate select committee on Covid-19, Brendan Murphy dismissed the fact that Australian aged care deaths make such a high proportion of Australia’s overall death toll as “a completely meaningless statistic.”

But surely the question of how our aged care residents are faring compared with ordinary Australian citizens is the most meaningful comparison of all. The figures suggest that we have failed to protect our most vulnerable to the same degree that we have protected “ordinary” citizens. They suggest a great disparity between the safety of Australian aged care residents and the safety of other Australian citizens. They suggest that aged care residents’ rights to remain free of the virus, and to live in environments where infection control is optimal, are not being upheld. Ultimately, they suggest that aged care residents have been kept in environments with unacceptable levels of risk, with no recourse to protect themselves, and no capacity to exercise personal agency or choice.

If it’s true that human catastrophes are best understood through the particular, it’s there where I’ll end, with just one fleeting image of the crisis in Australian aged care: of a dying ninety-five-year-old woman named Milka Keleman, who was found with ants crawling out of an infected leg wound in the Covid-19-stricken Kalyna aged care home in Melbourne, where she was supposed to be receiving palliative care. According to care workers, residents at Kalyna went without medication for up to five days, were not given food or water for eighteen hours, and went without showers or being cleaned for days. At one point, there were only two staff to care for sixty-eight residents. Carers found dried faeces caked on the floor that a nurse reported being unable to clean even with detergent and scrubbing.

Twenty-two residents at the Kalyna aged care home have so far died of Covid-19, but Milka was not one of them. She died of other causes: one of the countless aged care residents who have suffered unacceptable collateral failures of care as Australia’s aged care system has broken down.

Milka’s death notice, published in the Age, reminds us that behind the unfathomable numbers are citizens who deserve better, people who love and are loved. It reads: “Passed away peacefully 13 August. Beloved mother of Rudy and Carolyn and grandmother of Karl. We will miss you but have so many memories to treasure. You will be forever in our hearts.”

As she lay dying in her bed with a leg wound swarming with ants, Milka was not a “consumer” enjoying “choice” about aged care. She was a vulnerable woman — a mother and grandmother — who deserved much better at the end of her life from a system that was supposed to care for her. •

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

The post What happens when we treat aged care residents as “consumers” appeared first on Inside Story.

But we have been overlooking our nearest neighbour for so long that such a slip is hardly surprising. Turnbull devotes five pages out of 698 to the Pacific Island nations, including PNG, and then only in the context of the so-called Pacific step-up, under which Australia has increased its involvement in the region in response to greater Chinese interest. His only other mention of PNG is two sentences in a diary entry referring to a day he spent in PNG on his way to India.

So the fact that PNG faces the threat of a hidden pandemic has largely escaped our attention. “There is no Covid in most of the country,” says Glen Mola, professor of obstetrics and gynaecology at the University of Papua New Guinea and a leading figure in the nation’s health sector. “But there will be — it’s just a matter of time.”

Mola fears that once the virus reaches urban slums and squatter settlements in Port Moresby it will be very hard to stop. “This is where ten to twenty people sleep in the same room most nights,” he tells me. “Once a few people start getting sick and a few die, I predict people in these squatter settlements will disperse. Lots of people will think of going home to their rural village and at that point people will start taking the virus with them. So we will have these cascading epidemics.”

So far the official figures paint a more optimistic picture. As of 10 September, 507 positive cases and five deaths had been identified in the whole of the country, mostly in Port Moresby. But these figures have been revealed by only around 25,000 tests in a population approaching nine million. Australia, with its population of twenty-five million, has conducted 6.8 million tests.

The comparison is misleading in one sense. Most of the testing has been conducted in Port Moresby, which has a population of around 400,000 and where the first cases were detected in overseas travellers. Apart from an outbreak at the Ok Tedi mine — also the result of transmission from overseas — the assumption is that there are few positive cases in the rest of the country. That may be true for now, but it is hard to be certain when testing has been conducted in only half the provinces.

A variety of lockdowns have been introduced and lifted. In March the government declared a state of emergency, with non-essential staff of businesses required to stay home, bans on air and road travel, and restrictions on markets and roadside selling. But these prohibitions were not implemented in some cases and subsequently relaxed in others. In August a curfew was imposed in Port Moresby, schools closed for a fortnight and the wearing of masks made mandatory. Only two weeks later, though, despite the number of positive cases rising, prime minister James Marape lifted the restrictions, saying, “We have to adapt to living with Covid-19 for this year instead of taking on drastic measures.”

This may be the only realistic position to adopt in a developing country like PNG. Tonia Marquardt, medical manager for Médecins Sans Frontières in PNG, says that stage four lockdowns of the kind imposed in Victoria would do more harm than good. “Extreme restrictions in a population that really lives hand-to-mouth in terms of daily needs would do an enormous amount of damage. I think the best approach is to have a really strong response to clusters, locking them down quickly. and to be aware it will keep coming back and to respond strongly when there are outbreaks.” Mola agrees that a hard lockdown strategy would be difficult, particularly in urban areas, and says it could lead ultimately to mass hunger, looting and rioting.

Even before the pandemic, the PNG health system was woefully inadequate to meet the needs of its people. Crowds of sick people often gather outside hospitals, waiting to be triaged; only the more serious cases make it to emergency departments, where they face another wait to be admitted. In a nation where tuberculosis and malaria are widespread and outbreaks of polio have been recorded recently, only 2.5 per cent of GDP is spent on health, according to the World Bank, compared with 9.2 per cent in Australia. The government says there are only 500 doctors and 5000 hospital beds in the whole of the country.

“It’s a real worry that our health services don’t have any slack,” says Mola. “We have to flatten out the spread of the virus as much as possible so we can cope with the extra load on the health system. We don’t have the capacity to give all health workers full PPE” — personal protective equipment — “for every patient or every episode of healthcare. So health workers will get infected and when a minority get very ill and health workers are looking after health workers, people will get very frightened.” He recently advised couples to postpone having a baby because of the likely strain on the hospital system over the next twelve months.

The World Health Organization is working with the World Bank, the Asian Development Bank and the Australian and New Zealand governments to provide more resources for testing and more personal protective equipment. But the challenge in PNG is for the money and physical assistance to get to where it is needed. While Port Moresby hospital made plans months ago to deal with Covid-19, Mola says it has only just started receiving the money to implement them.

Australia hasn’t altogether ignored these problems. It has sent an Australian Medical Assistance Team of eight people, including public health specialists and laboratory experts, to PNG. Last month it announced an $80 million contribution to an international program to provide access to a Covid-19 vaccine for health workers and other vulnerable groups in Southeast Asian and Pacific countries. But the money comes from Australia’s existing, already meagre aid budget.

Earlier in the year the government promised $100 million to help Pacific countries deal with the economic effects of the virus. Papua New Guinea was allocated about $20 million. Again the money is what Canberra calls a “reprioritisation” from the aid budget. Given the scale of PNG’s budget problems it is a drop in the bucket.

Last year, Australia gave PNG a $440 million loan, meant as a temporary measure until the country refinanced its debt with the help of the International Monetary Fund; repayments were subsequently suspended in a sign of the scale of PNG’s economic woes, which have been greatly exacerbated by the pandemic. In May, Australia’s foreign affairs department conceded that “the scale of the Covid-19 crisis will dwarf the resources we have available, including through our ODA [Official Development Assistance] budget.”

What else can Australia usefully do? Provide more testing kits, for one, says Mola. And perhaps we could send them a Norman Swan, he suggests, or another credible medical figure to combat the rumours running rife. One is that the virus has been brought into the country by the WHO; another that it was the Bill Gates Foundation, which wanted to boost its vaccination business. And then there’s the resistance healthcare workers have encountered to measures to stop the spread because “it’s in God’s hands.”

China, among other countries, has been providing virus-related assistance, including tonnes of equipment, as part of the increased engagement with the Pacific that has made Australia nervous. Last month Scott Morrison also announced a “comprehensive strategic and economic partnership” with PNG. Effectively an update of previous such agreements, it is strong on rhetoric about enduring ties, strong democracies and improving healthcare, but contains few specifics.

But the agreement does reaffirm — under the heading of strategic cooperation — the redevelopment of the Lombrum naval base on Manus Island. Apart from having been an Australian dumping ground for asylum seekers, the island occupies a potentially important strategic position off PNG’s northern mainland. In June, the PNG government was reported to be planning to tear up the agreement reached in 2018, with the then PNG foreign minister Patrick Pruaitch saying negotiations had been mishandled by the previous government of Peter O’Neill and he had ordered a review. Pruaitch is among those in the government supporting a greater Chinese role in the region.

Judging by the Australian defence department’s response to questions, that tension has been smoothed over. The department says there has been no request from PNG to review the agreement, work has started on preparing the site for construction, and contractors are being selected “through an open and competitive tender process.” The department is coy about US involvement in the redevelopment, although it was part of the original announcement. “Cooperation between PNG and the United States is a bilateral matter for both nations,” it says.

Perhaps Chinese firms won’t bother to put in a bid. They are already doing just fine on other projects, including at Momote, which has the closest airport to Lombrum. This also is being redeveloped, with a longer runway and other work to upgrade the facilities. Performing the work is China Harbour Engineering, identified by former US navy officer Thomas Shugart as a subsidiary of China Communications Construction Company — which happens to be one of the companies building Chinese bases in the South China Sea and has been singled out for potential US sanctions.

When asked about Australia’s attitude to this work, Australia’s foreign affairs department played a straight bat: “Momote Airport is one of the many airports across Papua New Guinea being upgraded as part of the Asian Development Bank’s Civil Aviation Development Investment Program. Australia welcomes ADB funding of infrastructure projects and support to economic reform in Papua New Guinea.”

Papua New Guinea is not about to look any gift horses in the mouth, and can only benefit from competitive rivalry between China on the one hand and Australia and the US on the other. As Rowan Callick pointed out recently in Inside Story, “Port Moresby is shifting to Beijing as inexorably as its economy is declining.” He added that PNG was the only country in the Pacific to support China’s new security legislation imposed on Hong Kong when the matter came before the UN Human Rights Council.

If the concern about China, increasingly verging on paranoia, keeps strengthening in Australia, PNG won’t mind. It may mean that we finally give our nearest neighbour the attention it deserves, and at a time when it seems likely to be facing a growing Covid-19 caseload. •

The post Just a matter of time for PNG? appeared first on Inside Story.

Clearly, not enough. In Victoria, where the interminable debates over modelling and lockdown continue, it sometimes seems like groundhog day. Remember when “bending the curve” was introduced into the popular lexicon? March feels like years ago.

That’s part of the reason why, on 6 September, premier Daniel Andrews attempted a reset, unveiling a “road to recovery” that featured a graduated relaxation of lockdown rules, each step triggered by reductions in the number of new cases over the previous fourteen days. The last stage would only be reached after 23 November, and only then if cases had been kept at zero.

The plan responded to criticisms of a lack of transparency by making each stage explicit and publishing the modelling on which it drew, but the result was a fearfully complex schema with dozens of points of guidance at each step. Reactions ran the gamut from grim resignation to vocal outrage, with the underlying fear that the criteria for escaping lockdown were too stringent ever to be reached.

Victoria’s attempted reset has hints of more inclusive and decentralised approaches, but it was too much in the thrall of an epidemiological logic. The long haul of this epidemic will require a deeper commitment to trust as a two-way street between government and people, and a much wider repertoire of local self-management in crafting durable changes in social organisation to minimise transmission.

Buried in Victoria’s road to recovery was the news that suburban response units would be established to “provide a tailored local response to everything from contact tracing to outbreak management.”

The call for local responses put me in mind of one of my most rewarding jobs, back in the late 1980s, as executive officer of the Victorian Federation of State School Parents Clubs, an organisation with an illustrious history extending back to the 1920s. Throughout the 1970s it was led by Joan Kirner, who would later recount her experiences on visits, as premier, to far-flung corners of the state. Once the formalities were over and the (male) dignitaries had dispersed she would find herself surrounded by women animatedly exchanging news and views on a first-name basis. Incredulous men would ask their wives how they knew the premier, and invariably the connection would be through the state’s parent-advocacy movement.

Victoria was once a leader in community participation, not only in education but also in health, community legal services, and the many other locations where active citizenry is constructed. They were mostly dismantled by premier Jeff Kennett’s Thatcherite turn to privatisation during the 1990s, and they never regained their pride of place.

Not even now, perhaps. A revealing detail in Victoria’s proposed localised response to Covid-19 is the disclosure that the technology giant Salesforce will be contracted to provide a new information management system. Salesforce is a US$160 billion company that promises its users they will be able to “make decisions faster, make employees more productive, and make customers happier using AI.” Its data-visualisation product offers nothing less than “human advancement.”

Salesforce has quickly pivoted to the Covid-19 response with a set of tools devoted to tracking the epidemic and its impacts — in fact, an entire ecosystem to guide businesses in reopening. In this and other ways, the pandemic is revealing the contours of a new form of platform capitalism. In the United States in particular, where central government has abandoned any pretence at steering epidemic control, the vacuum has been filled by the private sector.

These information management platforms are themselves politicised. Salesforce is firmly on the Democratic side; among those lining up on the other side is Alexander Karp, chief executive of another data-management outfit, Palantir, who filed a trenchant statement with the company’s IPO on 25 August.

“Our software is used to target terrorists and to keep soldiers safe,” said Karp. “If we are going to ask someone to put themselves in harm’s way, we believe that we have a duty to give them what they need to do their job.” Many Silicon Valley technology firms use “slogans and marketing” to obscure the fact that “our thoughts and inclinations, behaviours and browsing habits, are the product for sale.” Better to choose Palantir, he concluded, because it wears its politics on its sleeve: “We have chosen sides, and we know that our partners value our commitment.”

These platforms offer to solve the problem of modern government by reducing it to a question of data organisation. The “old-fashioned” politics of community participation proposes a different answer. The pressing issues of pandemic control lie in how easily and quickly people can be tested, receive results, isolate if they need to, find income, food and social support, reduce their social mixing if they may have been exposed, stop working jobs in multiple locations, reduce the risk at worksites, and so on. The experience of the Victorian town of Colac, where an outbreak centred on the local meatworks, speaks of a community taking local control of the response.

My advice to Daniel Andrews? Amplify these signals, be prepared to trust communities to play a bigger role in the Covid-19 response: some mistakes will be made, but more decisions will be right than wrong. The trust needs to be genuine: devolve real power over how people mix and how they manage risk. It doesn’t play the game of adversarial politics, nor give a click-driven media the polarisation they crave — locked down or not? borders open or closed? — but it does give government more space to concentrate its efforts where they will make a real difference, by ensuring communities are supplied with the real-time information, infrastructure and supplies they need.

Meanwhile, more evidence from overseas that science and politics are poor bedfellows.

Last week’s news of a pause in the Oxford University/AstraZeneca vaccine trial was accompanied by quick assurances that occasional adverse reactions among participants are nothing unusual. Perhaps so. A participant in the trial was reportedly diagnosed with transverse myelitis, a serious spinal cord inflammation known to be triggered, albeit rarely, by vaccines. The trial resumed within days, indicating that its safety board didn’t see a substantial risk of adverse events, but the pause does dent the optimistic view that everything will go miraculously smoothly and a vaccine will be available in October.

Covid-19 has caused many of us to dust off the history of Spanish flu, which despite its name originated in a US army base in Kansas. Its impact was front of mind in 1976 when a swine flu outbreak occurred in the US army base, Fort Dix. It was an H1N1 flu similar to the 1918 virus, and US authorities saw a significant risk of a global pandemic. President Gerald Ford, who was up for re-election, announced in March that “every man, woman and child in the United States” would be vaccinated, and he himself was photographed receiving the rushed vaccine less than a month before he narrowly lost the election to Jimmy Carter.

Ford’s strategy wasn’t only politically futile, it was also a healthcare disaster whose legacy is still being felt. As early as April 1976 the World Health Organization had doubts about whether the new flu was likely to develop into a serious pandemic, and advised against rushing out a vaccine. Worse still, the vaccinations caused more than 450 people to develop the paralysing Guillain-Barré syndrome. The suspicion remains that public health and safety judgements were shaped by the political imperatives at play.

The race for a Covid-19 vaccine has been the most overtly politicised of the scientific challenges, but it is worth noting that no effective therapeutic drugs have yet been developed to treat the illness. The only real success to date has been the repurposed steroid dexamethasone. The reality is that the pathway from invention to successful trial conclusion is long and time-consuming.

The last of the potential game-changers is diagnostics, where a reliable rapid, point-of-care antigen test would transform the capacity for real-time control of the epidemic. That much has been recognised by British prime minister Boris Johnson, whose Operation Moonshot is a £100 billion plan to enable ten million tests nationally per day by early 2021. Perhaps unfairly, the plan — relying on an upbeat PowerPoint by another of capitalism’s handmaidens, the Boston Consulting Group — has been received with widespread derision. This is perhaps where politics ought to make its contribution to science: setting, testing, resetting and retesting the balance between realism and ambition.

Six months in, it is tempting to imagine this pandemic is nearly over. That is far from the case. As the next year unfolds, there are sure to be many trying moments. The temptation will be to run them through the prism of heroism or outrage. A more sustainable strategy may be to hold back on both. •

The post Roads to recovery appeared first on Inside Story.

This calculated shift leverages Victoria’s apparent success in curbing a Covid-19 upsurge that had peaked on 7 August at nearly 7000 active cases. That experience has been an object lesson in the dynamics of this epidemic — undetected transmissions getting out of hand within days and, once established, requiring massively curtailed movement and the tracking down of everyone to whom the virus has spread.

Other states are crossing their fingers they won’t experience anything on that scale. But avoiding outbreaks altogether is almost certainly a vain hope. Resurgent epidemics across Europe and in South Korea, and even the reappearance of cases in New Zealand after 102 “Covid-free” days, show the virus will relentlessly exploit uninfected populations. With 23.5 million reported cases globally and the real number of infections running at ten times that, attempts at elimination are futile. SARS-CoV-2 has established itself as a permanent part of the human condition.

Still an open question, though, is how much Covid-19 will contribute to the total human burden of disease, and here there is everything to play for. Hence the prime minister’s pivot to vaccine optimism.

Back in March and April, prognostications about a Covid-19 vaccine were cautious. No one wanted to repeat the mistake made with AIDS, for which a vaccine was promised “within months” back in 1984. Even today, despite a massive scientific effort, that vaccine remains elusive. But the mood around a Covid-19 vaccine began to change midyear, and by the end of July was buoyantly optimistic. At least four of the leading candidates had by then announced results of phase I and II trials that showed safe and well-tolerated products producing strong immune reactions.

But with success on the horizon, things began to get murky. First came a rush to lock in vaccine pre-orders, riding roughshod over the World Health Organization’s attempt to secure agreement on equitable and orderly distribution, as part of a plan to cooperatively accelerate and scale up every step from discovery to access. Leading the scramble for primacy was the United States, forcing other countries to place orders or establish special relationships with vaccine developers before future supplies were fully committed.

Vaccine nationalism also infected the race for vaccine discovery, with the tone again set by the United States. When he launched the US vaccine development effort Operation Warp Speed in May, Donald Trump spent more time talking up the American military than he did vaccines. It may have escaped attention that Operation Warp Speed is jointly run by the US Department of Health and the Department of Defense, with army general Gustave Perna as its chief operating officer. US vaccine partnerships are a mirror of its military stance: having failed back in March to buy up German vaccine company CureVac and move it to the United States, the Americans are having to spend a lot of money securing alliances with European and British vaccine developers.

Meanwhile, in a reversion to cold war tropes, Russia has named its Covid-19 vaccine Sputnik V. But an even greater risk to global cooperation in this new cold war is Trump’s refusal to contemplate any cooperation with Chinese vaccine development, a stance he may soon come to rue. At least three of the Chinese candidates are among the most advanced.

The biggest threat now to Covid-19 vaccine development is that the science of proving vaccine effectiveness will be subordinated to politico-military considerations.

On Sunday, on the eve of the Republican National Convention, Trump announced emergency-use authorisation of blood plasma as a Covid-19 treatment. Given that large-scale trials were already under way, this move smacked of desperation. Australia’s CSL boss Paul Perreault participated in a White House roundtable on using plasma back in July, and upwards of 30,000 patients are already being treated under the trials, which is probably around the maximum capacity for the therapy. Trump’s announcement offered no material advantage, though something will be lost if the plasma treatment is prescribed as standard care rather than as part of a carefully evaluated trial.

The emergency-use authorisation is itself a product of a militarisation of the health response. Introduced by the Project BioShield Act of 2004, it goes beyond the US Food and Drug Administration’s earlier processes for speedy authorisation of drugs under investigation, which had been much accelerated under pressure from AIDS activists at the end of the 1980s.

Amid the concerns about biological warfare during the “war on terror,” the United States felt the need for a drug or vaccine authorisation process more attuned to the scale of an attack. The current procedure was first used in 2005 after notorious security hawk Paul Wolfowitz, then deputy defense secretary, sought authority to deploy an anthrax vaccine against the imminent threat of an anthrax attack. Trump’s use of the authorisation for blood plasma is clearly a rehearsal for its use to authorise a Covid-19 vaccine on the eve of the US election.

When McKinsey and Company reviewed the increasingly optimistic vaccine landscape at the end of July, it noted that six vaccine developers had already signalled their intention to use some form of emergency authorisation for their products towards the end of 2020. The earliest candidate was from Oxford–AstraZeneca, signalling a September–October time frame for emergency use, followed by Pfizer–BioNTech in October, Moderna in the last quarter of 2020, and two of the candidates from Chinese developer Sinopharm in December.

The orthodox account of vaccine or drug development is that, having established safety and proof-of-concept efficacy in phases I and II, the effectiveness of the treatment is demonstrated in a phase I trial. Treatments are meant to move to regulatory approval only if they pass the effectiveness threshold in phase III.

The national and geopolitical pressures on a Covid-19 vaccine are blurring these lines. To shorten the time in which a vaccine can prove its effectiveness, the numbers enrolled in some of the phase III trials have already become massive — 60,000 for a Johnson & Johnson trial beginning in September, 30,000 each for Moderna’s and Pfizer’s.

Russia seems to have approved use of the vaccine developed by the Gamaleya Institute in advance of formal phase III trials, which are only just beginning. Meanwhile, China’s National Health Commission reported on 24 August that Covid-19 vaccines developed by Chinese companies had been authorised for emergency use back in July.

Last week’s vaccine optimism from Scott Morrison was accompanied by an avuncular promise of Australian largesse to extend vaccine access to the “Pacific family.” The PM may find that announcement is too little too late, given that three of the six vaccines already in phase III trials are from Australia’s rival in the Pacific, China, with two more, equally promising, Chinese products following closely behind.

As the vaccine scramble intensifies, so too will the challenge of sorting good data from bad. A pandemic vaccine ought to be the ultimate global public good, but when a powerful state not only uses its purchasing power to try to corner the market but also compromises the integrity of the scientific discovery process in the service of a political timetable, it turns the vaccine into a global public bad.

It may not be too late to rescue good science. Vaccine candidates need to be held to transparent and rigorously applied standards of proof against established criteria. A massive effort will be needed to hold to this core of truth while the inevitable emergency authorisations, and commercial and geopolitical brand-positioning are swirling around. Ultimately, though, this is the only strategy that will stand the test of time.

Australia’s accomplishment in keeping the number of Covid-19 infections low will give it the luxury of rolling out vaccination carefully. Priorities can be set according to need, and emerging hotspots dealt with by combining targeted vaccination with existing techniques of testing, contact tracing and isolation.

Importantly, flicking the switch to hope should not end the national conversations that Covid-19 has started. We have had a glimpse of what a better system of income support might look like, free of the impulse to punish the unemployed so they accept their status as a reserve army of labour. The shortcomings of a care economy grounded in underpayment (it was, after all, women’s work) have been laid bare and can now perhaps be repaired. These are opportunities to build back better, not snap back to worse. •

The post Mission accomplished? appeared first on Inside Story.

Precision public health followed, but was greeted with considerably more scepticism. Advocates saw it as the opportunity to tailor public health to the needs and experiences of increasingly precisely defined populations; detractors feared that genetic determinism would supplant close attention to the political determinants of health.

These discussions were swept aside in the urgency of the Covid-19 pandemic. Instead, authorities used public health tools that would have been familiar a century ago, even down to controversies about border closures and face masks. But reaching into the well-worn toolkit may have blunted some of the nuance required to deal with this pandemic.

Dominating the Covid-19 modelling and messaging have been probabilistic population measures: physical distancing, restrictions on movement, and other behavioural changes designed to slow the spread among those who might have been exposed. These quarantine measures, which seek to increase the distance between sources of infection, are always imperfect — borders are never hermetically sealed and behaviours never fully predictable.

Less attention has been given to the other side of epidemic control: the isolation of cases, with infection controls designed to prevent spread to immediate contacts. Unlike quarantine, which operates at population level, isolation and infection control operates at individual level, though it too is imperfect — witness how infections among healthcare workers have exposed the limitations of protective equipment in the real world of overworked hospitals.

So far, Australia’s Covid-19 response has been dominated by quarantine. When overseas arrivals were found to be lax with their self-quarantine, they were subject to hotel quarantine under supervision. This would give time for the disease to incubate in those who were infected but not yet symptomatic, who would be isolated.

In response to community transmission, those who take the test have been enjoined to quarantine themselves for fourteen days, with mixed levels of compliance. This is where it is unhelpful to conflate quarantine and isolation. People who have received a test are asked to regard themselves as if they might be positive, but the recommendation to self-quarantine has been made in a half-hearted way. The more stringent requirement — mandatory isolation until told otherwise by public health authorities — only kicks in once a positive result is received. But even then, isolation happens at home, and although infected people are advised to limit their contact with other household members, this is often unrealistic.

A more effective response might make a much clearer distinction between the blunt population-wide instrument of quarantine and the imperative of infection control through isolation of positive cases.

China gained control of its first wave of Covid-19 infections through an aggressive combination of both quarantine and isolation measures. Remember those pictures of the massive hospitals thrown up in a week in Wuhan? They were for the isolation of confirmed cases, and not only those who were sickest.

Striking the right balance is important. Isolation must not be seen as a punishment for contracting Covid-19: that would be the quickest way to deter people from testing and keep much more transmission under the radar. But the failure to isolate appears to have been a critical point of leakage in the current Australian response.

Biosecurity expert Jeremy Konyndyk of the Center for Global Development has noted, “We have a strong end game once there is a vaccine, and we have a strong opening game if countries contain an outbreak when case numbers are low.” But too often it is what he calls the “middle game” that is neglected. That judgement is very pertinent to Australia at the moment. With a Covid-19 vaccine tantalisingly close, the middle game is being neglected.

Covid-19 testing is another case in point. After initial efforts to decentralise the testing infrastructure, the current system — with a wait of at least a day for results — seems to have been judged “good enough.” But tests have been developed that can produce reliable results within half an hour. If a thousand or more mobile testing sites were deployed at points of care across Australia and delivered a positive result on the spot, the public health system could then swing into action with a personalised isolation plan: precision public health in practice.

The Therapeutic Goods Administration has approved at least three point-of-care nucleic acid tests, along with a number of point-of-care antibody tests (which are useful for determining who has been infected in the past but less useful to pinpoint current infection). It is not clear why these tests have not yet been rolled out.

Focusing too heavily on vaccine prospects amounts to dropping the ball during the middle game. Improving detection, control and treatment can have immediate effects, while many uncertainties surround the prospects for vaccines.

The hyper-competitive environment of vaccine nationalism has not helped. Moscow’s Gamaleya Institute has already developed a successful vaccine, and its registration is imminent — at least according to Russian health minister Mikhail Murashko. Unfortunately, data from the clinical trials has not been released, making it very hard to evaluate his claim. Of the vaccines that are being more transparently tracked, at least six have entered phase III trials, where their efficacy will be tested.

Vaccine optimism bring its own perils. Cutting corners in a scramble to find effective responses will not produce good and durable responses, and may make them much harder to find. The same applies to treatments. It has been suggested that Britain’s creation of a unified platform for Covid-19 treatment trials has produced reliable results more quickly than the free-for-all — thousands of small-scale trials of potential treatments producing more noise than signal — in the United States.

Paying attention to the middle game also means delivering on the opportunities to make lasting changes to the social and economic opportunities provided by the pandemic. The old post-disaster recovery slogan is to “build back better,” but if building better is left until after the disaster is over, then it will probably never happen.

The announcement that the final VCE results of all Victoria’s year 12 students will be based on an individual assessment creates a welcome opportunity to build a better system. Those familiar with the history of the Victorian Certificate of Education will recall that it was created on the recommendation of educationalist Jean Blackburn, whose report on post-compulsory schooling in 1985 was one of the high points of education reform in Australia.

As it was originally conceived, the VCE was to be the cornerstone of a flexible, individualised education assessment system, doing away with the single final-year score. This bold vision was successively watered down under pressure from universities and businesses, which wanted a single score, however spurious, to filter candidates for limited places.

So let’s welcome the return to a more nuanced and individualised approach to matching students with future pathways. Perhaps it is further demonstration of the promise of precision. •

The post Sharpening the instruments appeared first on Inside Story.

Australian aged care was already in crisis and a subject of considerable community concern before Covid-19’s arrival. In 2018, in response to serious and wide-ranging allegations of abuse and neglect aired on ABC Four Corners, the government established the Royal Commission into Aged Care Quality and Safety. Its interim report, simply called Neglect, concluded that “substandard care is much more widespread and more serious than anticipated.”

This “crisis” in aged care has been festering for at least the last two decades. Shaped by the Aged Care Act 1997, the Aged Care Quality and Safety Commission Act 2018 and numerous reviews in between, aged care has undergone considerable change during that time. Prior to the Aged Care Act, high-level aged care was effectively part of the health system and much of it was delivered in old institutional-style nursing homes. The new act was meant to better reflect what people said they wanted: a more social, homelike model with better facilities and a less clinical feel. “This is a person’s home, not a hospital” became the catchcry.

In response, homes became more “homelike” and the emphasis moved to social rather than clinical models of care. Nursing staff ratio requirements were abolished, with homes simply required to provide “adequate” care. The language changed to reflect this new approach. “Nursing homes” became “residential aged care facilities” (after all, having a nurse on the premises was no longer required) and the previous distinction between “low” and “high” care was abolished. State governments significantly reduced their role in providing and monitoring nursing homes, and bed licences were increasingly awarded to large national and multinational for-profit companies.

During these past two decades, both major parties have seen competition and the market as critical means of driving improvements in efficiency and quality, and both have sought to align with key industry and aged care consumer peak bodies. All these interests share a belief that consumers should be empowered to make choices, with more support on offer for people who choose to stay at home and providers encouraged to be innovative. The shared view was that rigid standards and regulations stifle innovation and responsiveness.

At the same time, population demographics and social values were changing. The baby boomers, now moving into older age, were more financially independent, healthier and better educated than the generation before. No longer was residential aged care a lifestyle choice: it was now the place you go when you have no other choice.

Two decades on, Australia’s 180,000 residential aged care beds are occupied by people who can’t live independently, even with formal community support, because of either physical frailty or dementia. My colleagues and I demonstrated this in 2018 when we independently assessed 5000 people living in residential care. Only 15 per cent were independently mobile, and most of that group had dementia. Half of the overall number required mobility assistance and more than a third (35 per cent) were bed-bound.

Yet aged care funding and governance has not kept pace with this development, and the pendulum has swung too far. Drawing on the rhetoric of a social model of care, governments, providers and some consumer peak bodies have been on the same page in declaring that there is no need for mandated nursing or allied health staffing or for rigorous clinical standards. After all, they argue, aged care is not healthcare and mandated staffing and clinical standards would distract from the need for the aged care facility to feel like a home.

While many homes provide good care, too many do not. On the funding side, aged care homes are now effectively funded for low care for a resident population that is demonstrably high care. Only 15 per cent of residents are receiving care that would be classified as four- or five-star in the five-star public rating system used in the United States. The sector requires a funding increase of about 35 per cent to bring it up to international benchmarks. Most providers want big funding increases but with no strings attached.

In this context, the arrival of Covid-19 created a perfect storm. Staffed predominantly by low-paid, often casual, personal care workers and with residents receiving an average of only thirty-six minutes of nursing time each day, many homes were simply unequipped to cope with the outbreak.

Infection control should be core business in aged care, not least because of regular flu and gastro outbreaks. Yet adequate personal protective equipment and training in its use have been lacking in many homes. Of 626 private homes in Victoria, about one hundred (with the number still increasing) have experienced an outbreak of Covid-19 and more than 1500 residents and staff have been infected so far.

Despite the experience at Newmarch in New South Wales (where fifty-six residents and thirty-four staff were infected and nineteen residents died), both the Commonwealth (as the level of government responsible for aged care) and providers seem to have been unprepared for the tragedy unfolding in private aged care homes across Victoria.

Notably, though, none of Victoria’s 178 public nursing homes has had a major outbreak. Even after controlling for size and location, this is an important difference. One fundamental reason is undoubtedly the extra funding and better nursing hours in public aged care homes regulated by the state government.

The federal government created a new aged care controversy this week when both the aged care minister, Richard Colbeck, and the secretary of the health department, Brendan Murphy, refused to provide a Senate committee with a list of Victorian aged care homes with Covid-19 among residents or staff. They did this in order to protect aged care homes from “reputational damage.”

For good public health reasons, it has been common practice throughout the pandemic to name schools, childcare centres, restaurants, hospitals and other venues where there has been a case. The decision to protect aged care homes from “reputational damage” is a powerful reflection on the relationship between Canberra and the private aged care industry. As a matter of good governance, it should not be the role of government to protect aged care providers from reputational damage.

The secrecy also cast a shadow over every private and non-government home. Given that this industry is 80 per cent funded by taxpayers, and given that people’s lives are at stake, where is the public accountability? This is not about blaming and shaming. We are living through a pandemic and it is about the public’s right to know. That said, aged care advocates took matters into their own hands and published a full list within the day. Aged care is increasingly a contested space.

A lot of hope is resting on the aged care royal commission, which will now not report until the first quarter of 2021. It is a once-in-a-generation opportunity to get aged care right. We cannot afford to keep getting it so wrong. •

This article first appeared in Pearls and Irritations.

The post The weakest Covid-19 link appeared first on Inside Story.

That’s how bad these numbers are. The 723 new cases the state reported on Thursday equate to 110 new cases per million people (or 104 in net terms, after correcting for earlier mistaken diagnoses). The thirteen new deaths amount to two for every million people.

Among countries with more than a million people, the global figures published by Worldometers show Brazil is the country where coronavirus is most rampant. On Wednesday it reported 333 new cases per million people, implying that on Tuesday alone, one in every 3000 people in Brazil was diagnosed with the virus. Victoria is not as bad as that, but it has entered that ballpark.

Colombia just pipped Brazil as the country where the virus did most harm on Tuesday, with 7.5 deaths per million people. All these numbers jump around — over the past twelve days, on average, Bahrain has been the top global hotspot for new infections, and Panama for new deaths from the virus. But if Victoria were a country, Thursday’s figures would put it among the twenty worst in the world.

The worst infection and death rates reported around the world yesterday were:

The United States and Israel were the only developed countries with higher infection rates than Victoria reported today. The United States, with four deaths per million people, was the only developed country with a higher death rate.

Had all the local commentariat who berated Sweden for trying a different path focused on where Sweden’s deaths were occurring, they would have seen something more useful for us than point scoring. Sweden recorded very high death rates between April and June largely because it failed to protect its aged care homes. Since then, it has gradually done so, and got on top of the virus in other ways; its current infection and death rates have been well below Victoria’s.

Had we been more alert to the lessons from outbreaks in the rest of the world, we would have realised that our Covid-19 policies must give priority to:

• Protecting those most vulnerable to dying of coronavirus — the elderly — by all means possible. We should have taken immediate action to remove factors that put them at risk, such as casual work contracts that fail to provide sick leave to the workers who care for them.

• Protecting migrant workers, especially those living in cramped shared housing and those who aren’t fluent in the language in which information and warnings about the virus are being communicated. Failure in this area was why Singapore went from being a global model to a global hotspot in March and April. Victoria failed to heed the lesson.

• Test, trace and quarantine. Victoria did lots of the first, but initially failed to focus on those most at risk of getting the virus or dying from it. The state’s capacity to trace contacts and inform them quickly that they were at risk was inadequate even in the good days, as the Cedar Meats outbreak demonstrated in April. That under-resourced team then became completely overwhelmed when the virus escaped from the quarantine hotels.

The core lesson from the rest of the world is that we need to identify our weaknesses and fix them as the first order of priority. It is not only Victoria that failed that test. The federal government, which has handled the crisis so well in other ways, failed it in relation to aged care homes, which are its responsibility.

In some ways Victoria was unlucky, but in the end it has become a global coronavirus hotspot by following the wrong priorities. It put too much emphasis on locking down the economy, too little on identifying and rectifying its vulnerabilities. The inquiry into quarantine hotels under Justice Jennifer Coate has too narrow a scope to pursue all the mistakes that contributed to the situation the state is in now. One suspects a royal commission will be needed down the track.

Australia is now in a lopsided situation. Most of the country has virtually no coronavirus activity, Sydney has a little and Melbourne has a lot. But that seems to be the global experience. An excellent analysis by Sweden’s Clara Guibourg points out that across Europe, a small fraction of regions have accounted for the vast majority of Covid-19 deaths.

Even in Italy, most of the Mezzogiorno (south) and central Italy recorded no increase in the total death rate when the virus was running rampant in the north. In Spain, the death toll climbed sharply in Madrid, central Spain and the northeast, but was only mildly higher in southern Spain and the far west. Most of southwest France showed no trace of the virus raging in Paris. Even large areas of Sweden were unaffected; the epicentre of that country’s death toll was Stockholm.

The same is true in the United States. Over the past three weeks, the statewide death toll has been below the national average in forty-one of the fifty states and above it in only nine. More than half the coronavirus toll is coming in just four states: Texas (where the death rate was twice the national average), Florida (ditto), Arizona (four times the average) and California. An outsize share of the rest was in smaller states across the Deep South (all but one, as it happens, with Republican state governments).

It’s a similar story here. Australia’s first wave of coronavirus was concentrated in Sydney, mostly from overseas travellers, although the state government shares the blame for allowing the single biggest breakout from the Ruby Princess. Its second, very much bigger wave is concentrated in Melbourne but also originated with overseas travellers under inadequate quarantine control, for which the state government bears responsibility.

In Europe, coronavirus has largely been brought under control. New outbreaks continue to happen — elimination is not a realistic goal until we have a vaccine — but so far (touch wood) on a much smaller scale than the conflagration in March. The Middle East, for some reason, is reporting lots of new cases but very few deaths. Latin America, especially South America, is now the epicentre of virus activity — and especially of those dying from the disease.

Australia gained global attention only as one of the island states that had managed to lock the virus out. It’s to be hoped that Victoria will win the struggle with the virus and bring it under control, as Europe has, as New York and its neighbours have in the US northeast, and as Singapore has in recent weeks.

But to keep it that way, we must closely follow other countries’ experiences, learn their lessons as they arise, and quickly put them into practice. •

The post Victoria, global hotspot 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. •

The post A world of needs appeared first on Inside Story.

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.

Just as it did elsewhere, the Victorian outbreak emerged out of clusters among casualised workers in meatworks, aged care, childcare, private security, fast food and freight. These are “essential workers” who are not covered by stay-home directives. (Nobody knows how many people fall in this category.) The work cannot be done from home, and the workers are often employed by labour hire firms and “booked” shift by shift. They don’t get sick leave or annual leave, and they may lose shifts, or the job altogether, if they are unwell and decide to isolate. Many are temporary migrants and ineligible for social security, so losing a job can mean instant family hardship.

Extended family and community networks are essential resources for coping with financial insecurity. Yet contagion travels easily when people work across multiple sites and jobs and even industries, and when community events bring many families together. This is how seeds can incubate into clusters and generate an outbreak of uncontrolled community transmission. Victoria has only just introduced modest, ex gratia payments for casual workers required to self-isolate; the ACTU has only just issued a call for paid leave for this workforce. We needed to have a hard conversation about inequity and vulnerability, and we dodged it, with terrible consequences.

One of the big distractions has been the manufactured controversy over masks. A field of commentators, led by UNSW’s Raina MacIntyre and the ABC’s Norman Swan, has maintained steady media pressure on the Australian Health Protection Principal Committee, or AHPPC, and the national cabinet to recommended mask wearing by the general public. This week, they had a significant win, with the Victorian government announcing $200 fines for anyone caught in public without a face covering. Yet the evidence for mask wearing is surprisingly thin, and the mask advocacy conceals a remarkably ambitious claim. Even as masks become part of everyday life, the controversy threatens to draw attention away from the drivers of Australia’s outbreak and the control strategies that are already known to work.

Apart from 5G protesters and sovereign citizens, nobody denies that masks work. The World Health Organization, the AHPPC and the Communicable Diseases Network Australia all recommend masks be worn by healthcare workers, who are most likely to encounter the virus. Experience on Covid-19 wards has shown that standard precautions, when followed carefully, have proven sufficient protection against infection. The paradox is that masks are effective when Covid-19 is either guaranteed or likely to be present. It is much less clear that masks offer any benefit when worn elsewhere.

The question is what masks work for. As I have noted, they are an effective personal protection strategy when Covid-19 is known or likely to be present. But mask advocates argue that requiring people to wear masks in public can be an effective epidemic control strategy — perhaps even capable of eliminating an ongoing outbreak if enough people wear them in daily life. Going further, they claim that SARS-CoV-2 is capable of airborne transmission, and accuse the WHO of refusing to acknowledge the evidence for this. If true, this would change everything.

Early in the pandemic, the WHO published technical guidance identifying droplet transmission — the transfer of trace amounts of respiratory secretions (spit and mucus) from an infected person, often via touch, to a susceptible person — as the primary route of infection. That’s why we all wash our hands frequently and avoid touching our faces, public surfaces and other people. (For more on the differences between droplets and aerosols, see this Inside Story explainer.)

This determination was based on a review of China’s efforts in contact tracing more than 75,000 cases during its initial outbreak, which coincided with mass internal migration for family celebrations of the Chinese New Year. If airborne transmission were even a minor probability, characteristic patterns of infection would have been visible — from space — in the contact-tracing data.

Aerosol scientists contend that droplets from coughs and sneezes — and perhaps even exhaled breath alone — can travel more than two metres and carry virus particles with them, posing a risk of airborne transmission. Responding to a recent letter with 237 cosignatories, the WHO updated its technical guidance. It observes that the studies cited in the letter don’t answer the “enough” question: do fine droplets from coughing, sneezing and exhaled breath carry enough virus to cause infection? Months later, epidemiological data still don’t support the claim of widespread aerosol transmission. Airborne viruses show much higher reproductive numbers and secondary attack rates than Covid-19 does.

The WHO said it remains open to further evidence regarding the “specific settings” — such as the choir cluster — that the letter cites to suggest airborne transmission has occurred. But it observes that these events could equally be explained by droplet transmission, and they already fit the risk scenarios identified early in the outbreak, which include face-to-face contact and spending two hours-plus in an enclosed space.

When Victoria first recommended wearing masks it used the same language — as an option in specific settings where physical distancing is not possible. Yet mask advocates called for a more general mandate. Chief among them, Professor MacIntyre is a media-savvy performer whose freedom to offer public comment is not constrained by any role advising governments on the crisis. She is adamant both that Covid-19 is airborne and that masks should be mandatory.

MacIntyre has led a number of experimental studies of mask wearing for personal protection and source control in healthcare and the community. And this is where it gets odd: MacIntyre’s own findings don’t support her claims.

A systematic review by the Cochrane Acute Respiratory Infections panel pooled data from fourteen randomised trials, including five led by Professor MacIntyre. It found no reduction in influenza-like illness in either healthcare workers or the general population as a result of masks. The one statistically significant result was that cloth face coverings are worse than even inconsistent use of surgical masks in general nursing. That finding came from MacIntyre’s own work. The reviewers note that many trials were poorly designed and lacked sufficient sample sizes, and none took place during a pandemic. Based on clinical experience during SARS, though, they recommend masks combined with other measures for personal protection.

In preparing an earlier piece, I combed through this literature along with studies of respiratory aerosols and virus deposition by air currents. A common theme emerged. Papers that don’t report significant effects — protective benefits from masks, or infectious virus in air currents — use the limitations section of their reports to undercut their own findings, offering post hoc rationalisations and calling for further studies. (In this way, even negative findings are interpreted as evidence of an expected, inevitable outcome.) Small sample sizes leave studies “under-powered” (unable to detect less common events), so their estimates come with very wide confidence intervals. MacIntyre’s largest study of masks was pulled up by peer reviewers for failing to adjust for confounders after non-random assignment of trial sites to the control and intervention arms. Following the adjustment, the findings were no longer statistically significant.

Conducting a systematic review or mathematical model can’t clarify matters when their inputs — the empirical studies — are poor quality. Modelling studies on mask wearing as an epidemic control strategy often assume degrees of effectiveness rather than using modest empirical estimates. One model, assuming 70 per cent effectiveness, concluded that mask wearing could eliminate the virus in a major US metropolis in a matter of weeks. You can see the problem if political leaders, taking that message to heart, decide that mask wearing is an alternative to lockdown.

The danger posed by the mask discourse is distraction. A distraction from what we already know, with certainty, about the virus and how it is passed on. From the drivers of this new outbreak, which are still workplaces, social events and family gatherings, most of which involve close and prolonged contact and are not covered by the mask mandate. From what works to control outbreaks, including aggressive contact tracing, testing and isolation. From banning the events and settings where transmission can occur. From dealing with huge gaps in lockdown arrangements that exempt essential workers, even though precarious work arrangements caused this second wave. And from the trust in our public health experts that characterised our early response.

Earlier in this piece I distinguished between using masks for personal protection and mandating masks for epidemic control. Working in HIV prevention, I encourage people to use whatever prevention method works for them, and I do the same with masks. If wearing a mask would make you feel safer, do it! Wearing face coverings can be a powerful expression of our shared commitment to ending the outbreak, and making face coverings lets us find creativity in dark times.

I wouldn’t be a health promotion worker if I didn’t tell you what to do, so here are two suggestions. Remember to change and wash your masks often, otherwise they will harbour germs just like a dirty hanky would. And remember that the situations of greatest risk are close contact and gatherings, not momentary breaches of the 1.5 metre rule in the supermarket queue. Stopping gatherings, and reducing contacts outside our household are both essential for interrupting chains of transmission.

As an epidemic control strategy, the case for public masking is strongest where prevalence rates are high and transmission is uncontrolled. Under these conditions, contact tracing and testing are overwhelmed. It is a “might as well, can’t hurt” strategy. When infection is rampant, even a small protective benefit can add up to a helpful difference in total infections. If I were in London, catching a crowded Tube service, I would wear a mask. But despite alarming numbers in Victoria, and ongoing “ember attack” in New South Wales, the prevalence in both states remains low, and thus masks are unlikely to make much difference.

Advocacy for masks is not informed by the brutal realities of crisis management and health communication. Thirty years of condom promotion show that just because a recommendation is simple does not mean it’s easy to communicate. The publicity blitz required to promote correct and consistent mask use comes with an opportunity cost. Airtime and public attention are finite resources. We need to concentrate on our epidemic drivers and reinforce public participation in high-impact strategies already proven to work. •

Bonus reading: A plain language summary of the Cochrane review by Australian experts Chris Del Mar and Paul Glasziou

The post Weapons of mask distraction appeared first on Inside Story.

Victoria and New South Wales are experiencing significant surges of community transmission of Covid-19, the inevitability of which was signalled well in advance. And because detection is not perfect and restrictions of people’s movement across borders is not absolute, there is no guarantee this won’t spread to other states.

The techniques of widespread testing, contact tracing and isolation are now well practised, and may be enough to curb these outbreaks. But they may also prove insufficient, in which case further restrictions on people’s movement may be needed.

In this environment, criticisms of the COVIDSafe app as an expensive dud seem strikingly misplaced. The $2 million price tag is only a small morsel of chicken feed when stood against the accountancy error that recalculated the cost of the JobKeeper scheme from $130 billion to $70 billion. More to the point, COVIDSafe will only prove its worth if transmission grows so fast that human contact tracers are overwhelmed. Given that case notifications lag behind exposure events, in other words, those Australians who have not yet done so would be well advised to download the app.

This week’s public debate about “elimination” versus “aggressive suppression” has largely been beside the point. We now have enough data to know that Covid-19 spreads easily, including among young people. Closing down workplaces, public gatherings and educational institutions will reduce the chances of transmission. Confining whole populations to home will reduce transmission even further. Any level of active cases is enough to seed further outbreaks.

There is an analogy to be made with “sterilising immunity,” the ultimate goal of any perfect vaccine. The goal is to create an immune response sufficiently strong to prevent a virus from taking hold in a body. The problem with applying sterilising immunity to the body politic is that its outcomes may indeed be sterile. As philosopher Roberto Esposito has pointed out, immunity is the opposite of community, so the task is how to balance the two in a way that ensures community is not snuffed out.

With the spread of Covid-19 to nearly every nation and territory in the world, we have plenty of models from which to choose. The June outbreak in China, centred on Beijing’s Xinfadi wholesale produce market, was brought under control after 335 local transmission cases, but it took a vigorous effort including localised shutdowns and eleven million tests within a month.

Hong Kong has entered what has been described as a third wave of infections, although the territory’s cumulative total of only 1400 cases means a daily spike into the teens is enough to register as a significant rise there. Hong Kong provides remarkably in-depth information about its Covid-19 cases: open up the map based on data from the territory government’s Centre for Health Protection and you’ll see identified cases right down to building level (as shown in the screenshot above).

Vietnam’s remarkable success deserves more comment, with a cumulative total of fewer than 400 cases and still no deaths. Most of the familiar elements are there: early, decisive action with border closures, quarantine, and school and workplace closures; and, over the longer term, extensive testing, active contact tracing and quarantine. Its contact-tracing model is perhaps the most telling: supported by a network of 700 district-level centres for disease control and more than 11,000 community health centres, contact tracing and attendant testing and isolation are routinely conducted for three degrees of separation: contacts of cases, contacts of contacts, and contacts of contacts of contacts.

Singapore remains perhaps the closest parallel to Australia. In July its daily number of new infections is closely paralleling Australia’s, and like Australia, it had initial success only to find that workers on the lowest economic rung, especially in close living quarters, were prime candidates for the virus. But, as the Anna Karenina principle would lead us to expect, there are important differences between the two countries’ experiences. An astounding 95 per cent of Singapore’s Covid-19 infections have been among migrant workers in dormitory blocks.

It’s these concentrations that have led Roland Bouffanais and Sun Sun Lim of the Singapore University of Technology and Design to suggest that much closer attention needs to be paid to “where the riskiest spots in the riskiest places — cities — might be.” This entails paying closer attention not only to places where people may gather for an extended time, but also to people’s behaviours when they’re gathered. It means attending to the differences between the mixing patterns of primary school children, who have a single set of classmates, and secondary students, who mix much more widely. It means using the datasets from phones, geolocated apps and public transport, and even from the people and vehicle flows collected by smart traffic lights, to build up a much more layered map of flows of people across cities.

Covid-19 control doesn’t come down to a binary choice between suppression and elimination. The settings need to be much more fine-grained than that. And to work so that communities are not alienated in the name of immunity, governments must make a much greater commitment to open information and participatory planning, alongside careful and detailed public health measures calibrated to risk.

Given the known risks of Covid-19 spread in abattoirs, for example, this should be an industry that only allows full-time employment with sick-leave entitlement, and all plants should have an in-house medical team. That might mean the end of cheap meat, but it seems an inevitable trade-off.

Workplace by workplace and block by block, we should expect Covid-19 risk to be incorporated into the pattern and rhythm of daily life. Against this benchmark, we ain’t seen nothing yet. •

The post Taking it to a new level appeared first on Inside Story.

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. •

The post A lesson in humility appeared first on Inside Story.

Mokak is leading the Productivity Commission team developing a new strategy for evaluating policies and programs affecting Aboriginal and Torres Strait Islander people. The commission sees this as an urgent priority: as its chair, Michael Brennan, wrote in the foreword to the draft strategy earlier this month, “despite decades of new policies and programs aimed at improving the lives of Aboriginal and Torres Strait Islander people, we know very little about their impact.”

“There’s huge variability in quality and practice,” Mokak tells me from his home in Canberra. “There’s no real central stewardship or central oversight.” While some agencies have “quite sophisticated processes” for dealing with research ethics, peer review and publication, for instance, others “haven’t even contemplated those things.”

Mokak says he’s seen “good and bad” approaches to assessing the impact of new initiatives during twenty-five years of working in Aboriginal and Torres Strait Islander policy and program management. But he has also witnessed a persistent pattern: governments launch initiatives and then move on, making little effort to determine what works and what doesn’t.

“Lots of activity, lots of policy development and design, lots of program implementation, but very little commitment to actually undertaking rigorous evaluation,” he says. “Often if an evaluation is required or thought about, it’s bolted on. It’s not planned for, and the objectives haven’t been negotiated with Aboriginal people, so the questions that need to be answered are kind of myopic.”

Mokak’s assessment is consistent with the overall decline in Australia’s public sector capabilities identified by the recent Thodey review into the public service. But he says Indigenous affairs has particular failings that have been compounded by history.

“What we found was Aboriginal people, Torres Strait Islander people are largely left out of the game in terms of planning and decision-making around evaluation,” he says. And this deepens the lack of trust between them and governments at all levels.

Mokak wants to turn things around by putting Aboriginal and Torres Strait Islander people at the centre of evaluation, because, as the Productivity Commission’s draft strategy recognises, “governments need to draw on the perspectives, priorities and knowledges of Aboriginal and Torres Strait Islander people if outcomes are to improve.”

Beneath this overarching principle, with its emphasis on “genuine engagement and partnership,” sit four subsidiary principles: all evaluations should be “credible, useful, ethical and transparent.”

“What I’m keen to do is to take a conversation away from just being about accountability and compliance and getting rapped over the knuckles,” Mokak says, referring to the research that shows Indigenous organisations are often loaded up with much more onerous reporting and financial accountability requirements than their mainstream counterparts.

He isn’t just interested in the kind of hard data — rates of employment, income, incarceration and disease, for instance — that characterises Closing the Gap. He wants to ensure that Indigenous people have the capabilities and opportunities to live the lives they value, in a context that affirms Indigenous identities, cultures and contributions.

As the draft strategy puts it, evaluations “should be in the areas that are valued most highly by Aboriginal and Torres Strait Islander people.” This means shifting from a deficit model — focusing on the gap and assessments of what Indigenous Australians lack compared with everyone else — to building on the existing wealth of experience and knowledge within Indigenous communities, and focusing on their priorities.

Romlie Mokak comes well equipped for what is undoubtedly a challenging job. He is a Djugun man and a member of the Yawuru people, traditional owners of the lands and waters in and around Broome. His role at the Productivity Commission had its genesis in 2017 when Malcolm Turnbull was prime minister.

“There’d been quite a rocky road with the Indigenous Advancement Strategy that sat within prime minister and cabinet,” Mokak explains. “What’s the IAS doing, what’s its effectiveness, et cetera?” The response came in the 2017 budget, which provided additional funding for evaluation and research and to establish an Indigenous Policy Evaluation Commissioner within the Productivity Commission.

Mokak took up the job in April 2019 after fifteen years “heading up black organisations.” He had previously been chief executive of the Lowitja Institute for Aboriginal and Torres Strait Islander health research, and led the Australian Indigenous Doctors’ Association for almost a decade before that.

“I was attracted to the statutory nature of the commission and the independence from government,” he tells me. “I was not anticipating that I’d immediately be leading a specific inquiry or specific study.”

The government’s letter of direction — essentially the terms of reference for developing an Indigenous evaluation strategy — arrived within days of his appointment. He says the project fits “hand in glove” with his other duties, which include contributing to the commission’s yearly report on government services, which assesses the equity, effectiveness and efficiency of state and federal programs in education, health, justice, emergency management, community services and housing; and chairing two working groups, one on Indigenous expenditure and the other on overcoming Indigenous disadvantage.

These working groups emerged in the 2000s when the Council for Aboriginal Reconciliation was seeking a better picture of the gap between outcomes for Indigenous and non-Indigenous Australians, and anxious to gauge improvement over time. While Mokak appreciates the intent, the concept of Indigenous “disadvantage” has always sat uneasily with him, because of the way such language frames Aboriginal and Torres Strait Islander people.

This frame struck Mokak when he took up his first Commonwealth job as a junior executive in the health department in 1998. “The section that I worked in was called Health Issues,” he says. “I should’ve seen the writing on the walls when I looked at that label, ‘Health Issues.’ Aboriginal people have just got health issues.”

Mokak acknowledges the influence on his thinking of the anthropologist W.E.H. (Bill) Stanner, and particularly Stanner’s 1968 Boyer Lecture, The Great Australian Silence. Reflecting on the lack of Indigenous voices in histories and commentaries, Stanner wrote that “inattention on such a scale cannot possibly be explained by absent-mindedness.” It must be structural, like “a view from a window which has been carefully placed to exclude a whole quadrant of the landscape.”

Mokak applies the same metaphor to “Indigenous disadvantage.” “If we look with that lens through that window, it continues to frame the disadvantages as our problem,” he says. “My children are not to be defined by the ‘gap.’ That’s not who they are.”

He wants to look through a bigger window, one that captures strengths, knowledge and experience without glossing over uncomfortable facts. As an example, he points to the Mayi Kuwayu study, which is looking at how Aboriginal and Torres Strait Islander wellbeing is linked to such things as connection to country, cultural practices, spirituality and language use.

Ironically, that first federal health job working on Aboriginal “issues” in the 1990s also gave Mokak an insight into the power of evaluations that have Aboriginal knowledge and experience at their centre.

“The big issue at the time was petrol sniffing,” he says, reflecting on his role as head of substance use policy in the early 2000s. “And there was bugger-all data.” The practice was known to be concentrated in specific geographic regions, and it spread “like wildfire” within a community once it started, because “sniffing leaders are very good at recruiting others.”

The best data on the problem that Mokak could find didn’t come from government sources, but from health services controlled and run by Aboriginal organisations in the Aṉangu Pitjantjatjara Yankunytjatjara lands in Central Australia. This gave Mokak and his team a baseline. They then developed a strategy whose most important element was an evaluation process, built on that Indigenous knowledge base, that would track what was working.

That early experience carries through to his work for the Productivity Commission. “A big part of this work is actually trying to reframe what evaluation means, what it should be about,” he explains. “It shouldn’t be about compliance, it should be about learning, it should be about a relationship, a reciprocal relationship, not just one-way traffic.”

Concrete proposals in the draft strategy include a new Office of Indigenous Policy Evaluation to work with an Indigenous Evaluation Council, which has a majority of Aboriginal and Torres Strait Islander members.

I suggest to Mokak that the thrust of his proposals is in keeping with the Uluru Statement from the Heart and the push for an Indigenous Voice to Parliament. “I was a delegate at Uluru,” he responds. “So, separately to my commission role, as a citizen, as an Aboriginal person, a constitutionally enshrined Voice to Parliament is something that’s very close to me.” He sees the Voice to Parliament, the Closing the Gap “refresh” and his own work on evaluation as all moving in the same direction, “which is about Aboriginal people having greater decision-making powers over their affairs.”

If government policymakers continue to think they know “what’s best for blackfellas,” he adds, “then that’s not where we’re going to get the results. Valuing Indigenous people, Indigenous knowledges, Indigenous priorities is fundamental. This is a part of that centring strategy for the evaluation strategy.”

He believes that Indigenous organisations have enormous strengths to draw on, and not only in the health sector. “Long ignored, this is a part of the continuing silence that needs to be really recognised,” he says. “That knowledge sits within communities and organisations, and those who are coming from outside need to have a bit of humility about trying to kind of access that.”

“Essentially, what is being done in the Productivity Commission now is what Aboriginal people have been talking about for a hell of a long time. The commission comes with a particular way of working, looking at the evidence, thinking deeply about that and then making some sense of it and providing some policy options to government.”

But will government listen and act on the results? When evaluations cast doubt over the value of high-profile initiatives — such as the use of cashless debit cards in Indigenous communities — governments often ignore, dispute or cherrypick the evidence.

“I’m not saying that this will be easy,” he responds. “It’ll require a bit of a mindset shift as well as a cultural shift, but I do want to emphasise that this is about really lifting the bar so that evaluations can properly look at the impacts of programs, policies on Indigenous people, with Indigenous people’s values, priorities, meaning, et cetera at the heart of it.”

While some people accuse him of living in a fantasy land, Mokak is happy to embrace a glass-half-full approach. “The government asking the commission to develop an Indigenous evaluation strategy is unprecedented,” he says. “The commission’s never had work as specific as this call and… I think there is a shifting climate, there’s different policy settings, and different discussions that are taking place.”

It’s true that governments will often talk about shared decision-making and genuine partnerships, he says. “What this strategy’s offering is how we do that in a really concrete way, ultimately to lead to better policies and programs, and Aboriginal people being at the forefront.”

After a pause, he adds, “It might be a rose-tinted view, Peter. But I’ve operated pretty well on optimism.” •

The post Closing the (effectiveness) gap appeared first on Inside Story.

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. •

The post Pandemic fatigue appeared first on Inside Story.

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.

The opening addresses from half a dozen heads of state were an impressive display of global commitment. Chinese president Xi Jinping made a US$2 billion pledge to the global Covid-19 response. Lofty words of commitment and unity were uttered by French president Emmanuel Macron, German chancellor Angela Merkel, South African president Cyril Ramaphosa and Moon Jae-in, president of South Korea.

Perhaps the most interesting — albeit by far the longest — of the opening addresses was given by Mia Mottley, prime minister of Barbados, on behalf of the Caribbean community. She tied together the pandemic, crippling debt and climate change in a call for moral leadership: “It is a crisis that calls for global leadership that will allow us to rebuild our humanity, our environment and the equity so badly needed in our societies and our economies. Covid has brought many of us closer than we have been with each other; it has equally cast a brighter light on the inequities in our society, but then it has also allowed the earth to breathe — yet again.”

The centrepiece of the meeting was its resolution on the Covid-19 response, which ended up being proposed by 146 member states, including Australia, the European Union and the African group. Like any highly negotiated resolution between sovereign states, it included a mix of motherhood statements, some real commitment on agreed areas of action, and a degree of constructive ambiguity. Those determined to pick over the entrails will debate whether the Australian government’s early call for an inquiry into the origins of SARS-CoV-2 and the WHO’s response shaped the final resolution, or whether some sort of review was always destined to be included in the meeting’s deliberations.

In the wash-up, the wording contained sufficient qualifications to accommodate both Chin’s view that an inquiry should happen only once the pandemic is over, and the push from other countries for it to be more urgent. It pledged to “initiate, at the earliest appropriate moment, and in consultation with Member States, a stepwise process of impartial, independent and comprehensive evaluation, including using existing mechanisms, as appropriate, to review experience gained and lessons learned from the WHO-coordinated international health response to Covid-19,” including “the actions of WHO and their timelines pertaining to the Covid-19 pandemic.”

The other sensitive part of the resolution was the extent to which it would mandate global cooperation in developing and sharing therapies and vaccines to treat and prevent the virus. Again the resolution held something for most readers: it recognised “extensive immunisation against COVID-19 as a global public good for health,” but only in a preambulatory paragraph, not in one of the “operative paragraphs” that carry the real weight of action.

Operatively, it did call for collaboration on the development of medicines and vaccines, including “existing mechanisms for voluntary pooling and licensing of patents in order to facilitate timely, equitable and affordable access to them” using the existing flexibilities in the international Trade in Services agreement, or TRIPS, overseen by the World Trade Organization. This did not go as far as the patent-pooling mechanism proposed by Costa Rica, but it did open the door for countries to use the TRIPS provisions that allow public health to override patent protections.

The way resolutions work in international forums like the World Health Assembly is that the wording is extensively negotiated prior to the meeting. When I first arrived in Geneva to work with UNAIDS, I was bewildered at being invited to observe an “informal informal.” Securing agreement between 193 sovereign member states requires a finely graduated deliberative apparatus. On technical issues — as opposed to elections, for example, or in the Security Council — resolutions are carried by consensus, making behind-the-scenes legwork essential.

Once a resolution is adopted, member governments can “disassociate” themselves from particular paragraphs. But that option has diplomatic perils — it is something of a sign of weakness both that you stand outside the global consensus and that you haven’t been persuasive on the substantive resolution. On Covid-19 the United States availed itself of this procedure, disassociating itself from the resolution on two counts.

One was the reference to sexual and reproductive health — for most UN members an unremarkable phrase but a target of right-wing American Christians who see it as code for abortion rights. The other was the references to patents — despite the moderate language and emphasis on existing mechanisms, the United States felt they “sent the wrong message” and gave insufficient regard to “the critical role that intellectual property plays in incentivising the development of new and improved health products.”

Much as the overwhelming majority of the World Health Assembly was upbeat in its collective resolve to tackle Covid-19 from a position of science, health and solidarity, a shadow was cast by the generally preposterous behaviour of the United States, utterly isolated in its oppositional stance. It began with a blustering address by US health secretary Alex Azar accusing the WHO of failing in its core mission. If the meeting had been an in-person affair it is hard to imagine he would have been able to withstand the collective scorn of the world’s other delegations. It continued with a threatening letter sent by Donald Trump, even as the meeting was in progress, giving the WHO thirty days to respond to his demands, or the United States would permanently freeze its funding and consider withdrawal.

We are used to the random relationship between the truth and Trump’s tweets, but somehow it was more shocking to see blatant falsehoods in a signed letter on presidential letterhead. The letter claimed that the WHO ignored reports of the virus in early December 2019, including in the Lancet, a claim the journal immediately refuted. It repeated the claim that Taiwan communicated information on human-to-human transmission on 31 December, despite the fact that Taiwan itself has explicitly backed away from that claim.

This manifestly false propaganda from the US administration is deeply corrosive of trust, even if in the end a more moderate solution may be agreed that allows the Americans to claim their concerns had been met.

Back in the real world, news from a number of the vaccine trials is starting to trickle out. The much-hyped effort by Moderna to develop a messenger-RNA vaccine — if it works it would be the first of its kind — came out with positive findings on 18 May that boosted its stock price, although it later fell back somewhat when investors realised the results were very preliminary and came from a company press release rather than a medical journal. Nevertheless, an immune response was found in twenty-five trial participants and neutralising antibodies were produced in the first four looked at — results across all forty-five participants in this first stage trial have not yet been reported.

Another of the closely watched trials from Oxford University released results showing that monkeys vaccinated with its vector vaccine were protected from lung infections, although the fact that virus was still detectable in their noses led to some questions about the level of protection provided.

The most substantial and thoroughly peer-reviewed results came from another vector vaccine being tested in Wuhan. These were the results of a phase 1 trial in humans showing the vaccine elicited strong immune responses with safety — suggesting the candidate vaccine was tolerated, albeit with mainly mild side-effects.

These are all positive developments, showing progress in getting vaccine candidates over the first hurdles of whether they produce an immune response and whether they are safe. But the road is still a long one — they must still prove they are effective in protecting against infection in people when they are actually exposed to SARS-CoV-2.

Developing a vaccine against a new coronavirus is painstaking, uncertain, incremental work. It doesn’t help that it is being undertaken in the glare of media scrutiny on behalf of an anxious public across the world. It doubly doesn’t help that share prices shoot up or plummet on every announcement. And it triply doesn’t help that geopolitical rivalries pivot on success. That is what the language of global public good is designed to guard against. •

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

The post Greater goods appeared first on Inside Story.

As the chart shows, the total number of deaths by 20 May varied dramatically between countries, with fatality rates among the worst-affected countries at the bottom of the ranking hundreds of times greater than those at the top. (Countries whose statistics are generally believed to be unreliable — including Russia and Brazil — are omitted.)

Apart from the East Asian countries, all of these countries are affluent Western democracies whose health systems are able to deliver quick and fairly reliable data on causes of death. They also happen to be the countries most affected so far, with just five — the United States, Britain, Italy, France and Spain — accounting for 70 per cent of all acknowledged deaths.

The figures in this chart are from Worldometer, with most of the data sourced from the Johns Hopkins University database on the coronavirus. They capture the picture as it was on 20 May. Global tables compiled in mid March would have looked very different, with China and Iran at or near the top, and they may well look very different again in a few months’ time. While numbers appear to be slowing in the countries so far most affected, it is feared the virus is spreading to other countries, some of them less well equipped to respond.

The figures almost certainly underestimate the pandemic’s death toll. Some causes of death are likely to have been misattributed, especially in the early days of the pandemic, and data isn’t always consistent between countries. (For a time, for instance, British authorities were including deaths in hospitals but not in nursing homes.) But the figures do reveal important trends.

The chart above is ordered according to death rates per million people. At the top are several East Asian countries and Australia and New Zealand, all with per-million death rates between zero and six. At the other end of the scale are several European countries: by far the worst is Belgium, which shares with Spain, Italy, Britain and France a death rate of more than 400 deaths per million people.

What explains the differences? One factor is luck. Countries that had the misfortune of facing the virus before epidemiologists understood its spread or health bureaucracies had strong enough evidence to persuade governments to take strong measures found that it had spread exponentially, with terrible consequences. The early outbreaks in Italy and Spain, for example, probably made those countries’ rates much higher. The unluckiest country, for a different reason, was South Korea. There, the virus took off among a secretive Christian sect, with 9000 people showing symptoms and infecting others. By the time the authorities found out, the coronavirus had spread widely.

Some say geography is a factor. Containment is certainly much more difficult among mobile populations. Such cosmopolitan destinations as New York, London and Paris were among the first to be hit, and it is hard for contiguous countries with closely meshed economies, like those of Western Europe, to close their borders.

Others point to distance from world population centres as a factor — in the case of Australia and New Zealand, for example — but both countries normally have high rates of international arrivals and departures. Besides, the most successful countries have included those contiguous to China, along with two of the most transited places in the world, Hong Kong and Singapore.

While geography plays some role, the table also shows strong differences between neighbouring countries. Portugal’s mortality rate, for example, is only a quarter of Spain’s. Ireland’s rate is substantially lower than Britain’s. Within Nordic Europe, Sweden’s rate (371) is far higher than Denmark’s (ninety-five), Finland’s (fifty-four) and Norway’s (forty-three). Several countries in northern Europe, notably Austria and Germany, have done better than their neighbours to the south. Canada has a lower fatality rate than the United States.

Luck and geography play a role, but a government’s response is much more important. And in dealing with a virus that proliferates as quickly as the coronavirus, the speed of decision-making is primary. With perhaps 80 per cent of those infected not needing any specialist medical treatment but still able to infect others, this easily transmitted virus can spread silently and speedily through a population. By the time the first case was confirmed in New York City on 1 March, epidemiologists believe, perhaps 10,000 people had already been infected in the city.

Covid-19’s exponential growth meant that time was of the essence. Globally the 1000th death occurred in early February and the 100,000th death just two months later, in early April. The United States registered its one hundredth death on 17 March, its 10,000th death on 6 April and its 100,000th death in late May.

When could governments have reasonably been expected to respond? Suspicions were growing in Wuhan in November and December following a series of strange and unexplained cases of pneumonia. China reported these to the World Health Organization on 31 December. The next day, the Huanan Seafood Wholesale Market, linked to several cases, was closed. The first Chinese death was reported on 11 January.

At that point the provincial and national governments were keeping vital information to themselves. Indeed, in early January, Dr Li Wenliang — who would die from the virus on 7 February — and other medical staff were accused by party officials of making alarmist statements and forced to retract. It was only on 14 January, according to the New York Times, that party leadership decided it was faced with an epidemic.

The Chinese government finally warned its population on 20 January. Three days later it quarantined Wuhan, took drastic action restricting the movement of its citizens, and sent in thousands of medical staff from elsewhere in the country. It can rightly be criticised for its secrecy in the first three weeks of the year, but from then on China was clear about the dangers. The World Health Organization proclaimed a public health emergency of international concern — its highest-level alert — on 30 January. It underlined the point on 11 March by using the term “pandemic,” but the 30 January announcement should have been sufficient to alert governments.

So, from the beginning of February at least, governments around the world should have been preparing for a possible pandemic. No grounds yet existed for lockdown measures, but governments should have been preparing tests, gathering personal protective equipment, ensuring hospitals had ventilators and other needed equipment, storing up masks for the general population, and, in federal systems, coordinating resources and policies among the states.

Taiwan, which monitored the situation in Wuhan closely from 31 December, seems to have been the fastest to respond. It and the other East Asian countries had suffered from several epidemics in recent history — bird flu in the 1990s, SARS in 2003 and swine flu in 2009 — experiences that had no doubt helped them to build expertise and encouraged them to take the threat seriously from the beginning.

Several Western countries, by contrast, were slow to respond. The most bizarre of all was the United States. Donald Trump’s daily intelligence reports had been warning of the threat of a pandemic, yet the president said no fewer than fourteen times that the coronavirus would go away. “We have it totally under control. It’s one person coming in from China, and we have it under control. It’s going to be just fine,” he said on 22 January. “Looks like by April, you know, in theory, when it gets a little warmer, it miraculously goes away,” he said on 10 February; and besides, “We’re very close to a vaccine.” Even as late as 9 March, just two days before he finally announced some dramatic moves, he tweeted, “The Fake News Media and their partner, the Democrat Party, is doing everything with its semi-considerable power… to inflame the CoronaVirus situation.”

These absurdities have real-world consequences, especially when combined with the lack of institutional mobilisation. One epidemiological study by Columbia University concluded that if the United States had begun social distancing a week earlier, 36,000 fewer people would have died from the epidemic by early May; and if they had begun two weeks earlier, 83 per cent of the deaths until early May would have been avoided. A cut-through line the Democrats can now use — which has the advantage of being broadly accurate — is that Trump’s six wasted weeks cost 60,000 lives.

After the death rate, the second key indicator is testing. The chart below ranks countries according to the number of Covid-19 tests carried out per million people, along with the number of cases per million. These 20 May figures again show the importance of bearing timing in mind. Among the European countries at the top, with the highest rates, most testing was done after the pandemic had already taken hold. South Korea doesn’t rank highly, but it did a lot of early testing as part of its very successful containment program and by early March had conducted several hundred more tests per head of population than the United States.

Partly as a result of the lack of a longitudinal dimension, the ordering of the table shows little relationship to the death rates in the first chart. The countries that most successfully contained the virus took different routes to success. Taiwan and Japan succeeded with limited testing; Singapore initially undertook limited testing, but after a second wave it escalated its testing regime enormously.

Perhaps the East Asian countries, with the social discipline that must come from both recent experiences of epidemics and a cultural respect for authority, will be able to contain the spread without extensive testing. But my guess is that in Western societies the scale of testing is going to be a key to reopening economic and social life.

By 20 May the United States’s testing performance was around average among these countries, which contrasts vividly with several clearly false statements by Trump. “We have tested much more than anybody else times two. We’ve tested more than every country combined,” he said on one occasion. “So the media likes to say we have the most cases, but we do… by far the most testing,” he said on another. “If we did very little testing, we wouldn’t have the most cases. So, in a way, by doing all of this testing, we make ourselves look bad.”

The claim that the high number of tests makes it seem as if the United States has a high number of cases is refuted by the second column of the chart, which shows that the United States has the third-highest number of cases per million people.

Rates of cases detected are one thing, but what about different death rates among those who fall ill?

The third chart, below, compares rates of death among the same group of countries; the lower the number, the better. If all countries were testing at the same rate on the same criteria, these figures would reveal a combination of two things: the vulnerability of populations and the effectiveness of medical interventions to save lives. But testing rates, and hence the number of cases identified, differ greatly between countries. Where fewer tests are conducted, they generally target people who already have symptoms or have been exposed to a dangerous cluster; where more tests are carried out, we get a better sense of the extent of infection in the general population.

With this important reservation in mind, what does this final chart show? As in the first chart, and with similarities in rankings, the differences are stark. Someone who contracted the virus in Belgium had about twelve times the likelihood of dying as someone in Australia. In fact, Australia, along with New Zealand and the East Asian countries, is at the top of the rankings.

The similarity between the first chart and this one suggests that the most important factor determining a successful response is not the vulnerability of national populations. Japan, for example, has the oldest age structure but a below-average Covid-19 mortality  rate. Nor, at least at this crude level of comparison, does success seem to correlate with any longstanding institutional strengths in healthcare systems. Indeed, rather embarrassingly, the Global Health Security Index of 2019 declared the United States and Britain — neither of which could be said to have successfully handled the pandemic — as the most capable among the 195 countries examined.

What the chart points to yet again is the importance of leadership and the speed of response. Rather than reflecting pre-existing weaknesses in their health system, the case–mortality ratio in the European countries, for example, reflects how quickly their health systems were overwhelmed. •

The post What worked to minimise Covid-19 deaths, and why? appeared first on Inside Story.

In hospitals and care homes, staff and patients are on the front lines of a daily struggle for life against the fiendishly complex virus that is SARS-CoV-2. Scores are still dying each day, an undue proportion black and Asian, making the country’s toll of deaths per million inhabitants the world’s third-highest.

The economy is stripped to the manufacture, import, delivery and sale only of essentials. Schools, universities, arts venues, libraries, places of worship are closed, as are most shops. Millions are confined to home, excepting forays to buy, exercise, get medical help or make limited social contact. Windows in residential streets are festooned with children’s rainbow drawings and tributes. “Thanks to key workers and our NHS! Better times ahead!” is one of dozens in my neighbourhood.

The workforce is in limbo: the more secure on furlough, the bulk of their wages guaranteed until October by the exchequer and then by employers; others are increasingly on site; many depend on welfare, emergency funds or savings. A deep recession is under way, officials projecting a 30 per cent fall in GDP between April and June this year as state borrowing balloons. Railway and coach travel is near frozen. Business models that assume close physical contact (sports, aviation, tourism, hospitality, high-street retail, fashion, catering, gyms, restaurants, cafes) are on ice.

Parliament, TV punditry, teaching, festivals and conferences are scrambling onto Zoom or Pexip. Broadcast news has segued from journalists’ stopwatch need-to-know explainers into endless heartbait. Newspapers’ print versions, already embattled, are further shrinking as advertising revenues plunge.

The government is assailed for shortcomings in basic duty of care, testing, equipment and communication, its early delays and missteps having made its subsequent efforts a colossal but flawed catch-up. Prime minister Boris Johnson, visibly sapped after a close call in intensive care and facing a competent new Labour leader in Keir Starmer, is needled by Scottish and Welsh leaders, rash in defending his chief adviser Dominic Cummings over an alleged breach of lockdown rules, and breezing his way through every encounter.

Never in the United Kingdom’s post-1945 history have so many ingredients fermented so quickly into so heady, and contradictory, a brew. They include the state’s own fissures, with the post-1997 devolution of powers to authorities in Scotland, Wales and Northern Ireland effectively reducing the United Kingdom to England in health and education policy.

The macro level forms but half the story, the other being the virus’s myriad psychic impacts on everyday lives. That can mean fears of losing health and job, and the pains of separation and the stresses of a constricted world, yet also the joys of car-free streets, freedom from commuting, cleaner air, thrilling birdsong, nature exultant. Everything, outside and inside, is in movement at the same time.

No wonder questions of meaning, purpose, choice and change, both individual and national, have acquired a new sharpness. Visions of the post-epidemic future — more green, equal, united and caring, or an authoritarian dystopia — abound. So do toolkits and slogans: build back better, great reset, new social contract. Henriette Roland Holst’s ageless poem on her native Holland lends itself to the moment: England, you give no space but to the mind.

Such dreams will be shaped, if at all, in the forge of corona-age politics. For now, their undoubted allure carries a hint of twin flaws: wishful thinking, and self-distancing from a moment whose nub is that the youthful SARS-CoV-2 continues to run the show.

In step with the struggle to define the future is a contest over the pre-epidemic past. Eventually, at least one official inquiry will assess the UK state’s performance in the context of its plans for an emergency of this type. This is already much discussed, even as the country’s share of the Covid-19 trauma has just got going. Close scrutiny of Boris Johnson’s own role is as certain as that of Tony Blair’s over the Iraq war, which was examined in Sir John Chilcot’s 2016 report. So too is attention to the performance of government departments, affiliated scientific committees, public health agencies and political advisers. Still, a lidar-like focus may be needed to penetrate layers of hindsight, covering of backs, shuffling of responsibilities: all familiar from the legion of “blunders of our governments.”

On previous form, the flagship inquiry — likely to pre-empt the one on Brexit, whose final curtain Covid-19 may well hasten — will take years (Chilcot lasted seven). By then, the court of public opinion will long have delivered its own verdict, which could land severely on some experts as well as the prime minister. Already published committee records and detailed media reports converge on a story of initial, fatal misdirection compounded by a series of analytical and logistical errors. Even in a fluid crisis where so much is provisional, that account will be hard to shift.

The story’s first part notes that Britain’s pandemic plan, drawn up in 2011 and still operative, foresaw the principal threat as a new strain of influenza. This judgement reflected the swine flu outbreak of 2009, sparked by the composite H1N1 virus. In that case, around £1.2 billion ($2.2 billion) was spent to allay the expected thousands of deaths, though they ultimately numbered only 214 out of 540,000 cases. Dame Deirdre Hine’s official report on H1N1 advised an incremental, follow-the-data approach when the next epidemic hit, plus wariness about worst-case assumptions. A contiguous factor here is that there was painful institutional and local memory of the 2001 foot-and-mouth outbreak, when a frenzied response saw millions of animals slaughtered and £8 billion ($15 billion) burned, but no memory at all of SARS-CoV-1.

Influenza, not corona; wait and see, not get ahead; and, to complete the set, darkness not light. In October 2016, a big simulation of an H2N2 flu pandemic was held under the aegis of Public Health England. It found that the National Health Service would be overwhelmed, identified likely shortages of personal protective equipment, or PPE, and highlighted care homes’ vital role in relieving hospitals. Alarming as the exercise was, its report stayed under wraps. That the simulation took place just as Britain was walking deeper into the all-consuming Brexit mire under Theresa May might be contributory to the lack of practical follow-up. In shadow, the seeds of yet another blunder germinated.

The story’s second part begins weeks after the novel coronavirus had been identified in the wake of the Wuhan outbreak, and its full genome sequence released by Chinese scientists on 10 January (which allowed Sarah Gilbert of Oxford’s Jenner Institute, among others, to immediately start working on a vaccine). Relevant British bodies were tuning in to its spread, even more so when the first local cases, of two Chinese family members in northern England, were recorded on 31 January — by coincidence, the very day Britain left the European Union and entered a transitional period for trade talks.

Those distractions partly explains why, until late February, coronavirus was seen by the political-media class almost exclusively as “over there.” A collective jolt arrived in the first week of March, with the first local death, the number of cases passing a hundred and Johnson announcing a £46 million (A$86 million) fund for testing and vaccine research. Still, a sketchy government plan (“The UK is well prepared to respond in a way that offers substantial protection to the public”) had zero sense of urgency.

In public, Westminster’s stage-set approach, with its reassuring mantras (“contain, delay, research, mitigate”) and studied politesse between government and scientists, projected harmony. But the twenty-one days until the lockdown began on 24 March would incubate problems so fatal as to make what came later a giant work of repair. Test-and-trace plans aborted, care homes exposed, medical stocks insufficient, frontline staff under-protected, border monitoring and quarantine procedures absent: each of these had a distinct source, but linking several of them was a lack of reliable data and of systems capable of delivering, processing and acting on that data. Notionally in charge, government — inevitably, perhaps — floundered.

Much of this was owed to the way the ambiguous inheritance of those what-to-do-in-an-emergency files played out against the baffling unfamiliarity of the latest epidemic. The government in early 2020 was “hypnotised by its own plan,” writes Ian Leslie in the New Statesman: “Faced with the novel problem of an untreatable, highly transmissible virus, the government’s current advisers seem to have found it hard to break with the plan they had — now unfit for purpose — and think anew.”

An initial failure to gauge the disease’s threat had shrunk the bandwidth that, if available, might have allowed different options to be explored. Practical lessons from East Asia were neither sought nor applied. There was a crucial deficit of imagination. That bland 5 March plan was wrong: Boris Johnson’s government would lack not just knowledge and tools in taking the initiative against Covid-19 but also the ability to remedy that lack. In contrast to supermarkets’ pinpoint circuits, it had no way to conjure instant operative resilience out of sparse warehouses and uncertain suppliers in a just-in-time economy.

Among the many compelling sub-themes of this two-part story is one with a singular local twist: a shift in science’s public profile from neutral expertise towards competitive partisanship. Its pivot was the government’s mid-March volte-face from an overhyped “herd immunity” approach to a more interventionist one. The notion of allowing mild infection of the healthy young while shielding the vulnerable, mentioned on the BBC by David Halpern of the Behavioural Insights Team and repeated by chief scientific adviser Sir Patrick Vallance at a press briefing, was first twisted into a form of eugenics, even genocide, then buried over a frantic weekend when a paper by the Imperial College mathematician Neil Ferguson and colleagues found that without rigorous physical distancing, Covid-19 deaths could reach 250,000 or more. The path to shutdown on 24 March, ranking among the most consequential days in British history, was set.

The switch was opposed by a vocal libertarian minority that cited evidence of Covid-19’s varying risks and impacts to argue against social closure. Some fire was directed at Ferguson himself, whose costly advice in the 2001 outbreak was disinterred. Behaviourists, economists and public health specialists widened the fray in lamenting epidemiology’s new stardom. Most telling was that the contretemps began to deflate harmful veneration of what ministers were jarringly calling “the science.”

This nebulous entity had been the government’s face-shield from Covid-19’s onset, invoked to parry every doubt over its decisions. It had the additional benefit of implicitly defusing a barb dear to opponents of Boris Johnson, his government and Brexit, its flagship cause: that these Brexiteers held “experts” in contempt. That barb dated from a late stage of the 2016 referendum campaign on EU membership, when justice secretary Michael Gove, still a key Johnson ally, told Sky News’s Faisal Islam during a gladiatorial interview that Britain would be “freer, fairer and better off” if the country voted to leave the European Union.

To Islam’s litany of twelve power centres whose leaders wanted the country to remain in the Union — including the US, the IFS, the IMF, the CBI, NATO and the NHS — Gove retorted, “The people of this country have had enough of experts from organisations with acronyms saying they know what is best and getting it consistently wrong.” Seizing on a fatal pause in mid sentence, Islam’s sharply incredulous double repeat of Gove’s first ten words launched these as the story. Gove’s unwise “had enough of experts” rode the media carousel — nonstop, into every crevice, for four years — as a symbol of crass, self-harming populism.

It was a gift that kept on giving. Never mind the sources, feel the clicks. Post-corona, dozens of “the experts are back” columns and “who needs experts now?” jibes wrote themselves. At the food chain’s pinnacle, “Boris Knows He’s Out of His Depth. Suddenly Experts Are Useful Again” was the Times headline on its 9 April interview with the geneticist Sir Paul Nurse, Nobel laureate and director of London’s state-of-the-art biomedical Crick Institute, whose Brexit views go without saying. “It’s galling when people who have denounced experts then come on the stage and start talking about experts. It doesn’t fill you with great confidence.”

The spectacle of experts’ disagreement over Covid-19 pulls the plug on the mirthless funfair. To the extent that this bombshell reflects dimly on Britain’s general level of scientific literacy, anti-Brexiteers’ pathological reductionism bears some responsibility: no chance of an “experts” sneer ever made way for a defence of the scientific (far less the democratic) value of pluralism.

The breakthrough here is that scientists (the “experts” du jour) are now part of the same cacophonous public space as everyone else. Many — along with active politicians, TV anchors, sportspeople, clerics, lawyers, academics, novelists — are now daily commentators, even capable (another thunderbolt) of drawing unfounded conclusions from false assumptions and dubious data. That the government’s Scientific Advisory Group for Emergencies, or SAGE, has spawned a dissident body, Independent SAGE, led by former chief scientist Sir David King, is the paragon’s last breath.

This is but one sub-theme of the British story that the virus has acted to dissolve and reconstitute: in effect, as an agent of influence. So when ministers are chided for leaning on “the science” they don’t disclose to avoid questions they don’t answer, when Neil Ferguson “steps back” after admitting to private assignments that violated lockdown codes, or when the public health guru John Ashton and Lancet editor Richard Horton are — as a duty to the audience, and at long last — gently reminded by broadcasting hosts of their political credentials and rhetoric, it is another little victory for SARS-CoV-2.

A forlorn government is differently exposed when its crutch, “the science,” is kicked away. No more can it so limply pass over responsibility for judgements it needs to own. That presents a new maximum test to ministers: can they convey the balance of risks with a literate awareness of scientific and political complexity? An immediate test too, as the government now plans for schools in England to reopen on 1 June as part of the lockdown’s staged easing, against strong resistance from teaching unions and parents.

Boris Johnson looked unready to reach this high bar even before the latest drama to consume his government. This was the furious reaction to Dominic Cummings’s family drive from London to his parents’ farm near Durham, northeast England, where the adviser and his journalist wife Mary Wakefield, both showing symptoms of illness, wanted to deposit their small son while themselves going into quarantine in an outhouse. Every detail of that choice is now being parsed for clinching evidence of what Cummings denies, that the trip broke the government’s then guidance to “stay home.” Genuine anger mixes with revengeful glee as the co-architect of Brexit and of Johnson’s general election victory in December, hated by many on both counts, flirts with Nemesis.

Cummings’s hour-long press conference in the Number 10 rose garden on 25 May, hours after the morning’s paroxysmic headlines, began with his chronicle of a family under pressure of illness and overwork. He described his movements as “reasonable” in the context of “weighing complex decisions to do with the safety of my child and my desire to go back to work.” Lobby journalists then all but accused him of arrogant, elitist hypocrisy in flouting orders he expected the plebs to observe.

Always careworn in appearance, Cummings is an independent-minded strategist whose intellectual seriousness, ambition and impatience radiate equally from his fertile blog. The media’s reflexive hostility over this (in British terms) uncommon radical recently erupted in intense criticism over his attendance at SAGE meetings, on the grounds that he was a political pollutant in scientific waters. This fizzled out when a few SAGE members said he mostly listened or sought clarification for the prime minister’s benefit. SAGE member Jeremy Farrar subtly wishes for more such interaction “so that advice goes directly into policy,” while blaming “not right” decisions made early in the crisis for a UK epidemic “that at least to some degree could have been avoided.”

The latest Cummings episode may also fade, though the Independent’s John Rentoul holds that only his departure can allow the people’s trust in Johnson to be rebuilt: “The public has already decided that he and Boris Johnson think that the rules for the little people don’t apply to them.”

The government’s errant choices pre–Covid-19 await their moment. So do incipient tensions between that other awkward duo, politics and science. Beyond the half-world, SARS-CoV-2 remains in charge. Those better times ahead will be a long haul. •

The post Covid-19’s awkward couple appeared first on Inside Story.

Australia’s mental healthcare system has long been fragmented and under-resourced. Despite increasing rates of mental illness, and despite the impact on individuals, families and society, services fall well short of demand. The coronavirus made the problem worse, and has highlighted how much needs to be done to provide adequate care.

To their credit, Australian governments have recognised the need to act. But so far they haven’t done enough. A bigger investment is needed to ensure that Australians in distress — whether they’ve had direct exposure as patients or healthcare staff, are elderly, disabled or isolated, or are suffering from joblessness or anxiety — get help in a timely fashion, and to prevent suicides from outstripping the coronavirus’s toll to date. Given that the economic adversity may have yet to peak, the damage to mental health and wellbeing could well intensify.

Studies of the impact of other pandemics — SARS, Middle East respiratory syndrome, influenza and Ebola — have shown how these engender fear, anxiety, emotional distress, and post-traumatic stress symptoms. Other studies have shown how global economic crises can affect mental health and lead to an increase in suicides.

Recent Australian surveys highlight the nature and extent of the mental health problems caused by the coronavirus pandemic and the economic downturn. Significant numbers of respondents to a survey in April by YouGov feared they would be unable to pay their bills (60 per cent), they would lose their job (49 per cent), they would not be able to feed their family (48 per cent) or they might lose their home (38 per cent). Home schooling and caring for children in isolation for longer periods is adding to the stress. The survey found a large increase in the number of Australians drinking alone, and one in four relationships under strain.

Researchers at the Australian National University came up with similar findings. But while two-thirds of respondents reported feeling anxious or worried, the survey also picked up an increase in social trust and cohesion.

A study by UNICEF Australia looked specifically at how the coronavirus pandemic and the associated lockdown is affecting teenagers. Almost half of young people surveyed reported an increase in stress and anxiety, with higher rates for girls than boys. Much of this is attributable to the uprooting of their lives, with nearly nine out of ten having had to stop seeing their friends and most having had their education and extracurricular activities disrupted or stopped entirely.

In the weeks since these surveys were conducted conditions have almost certainly worsened, especially for adults, as the economic impacts of the coronavirus shutdown become more apparent.

Mental stress, which ranges in intensity from mild anxiety to severe post-traumatic stress disorder, disrupts normal brain function and causes impairments in learning and memory. Chronic stress influences the onset and severity of depression and cognitive decline, and it affects the body even at the genetic level. The physiological consequences of stress depend on the intensity and duration of the stress factors, and different people will perceive and react to these differently depending on their resilience. These differences help explain why some people are struggling while others are finding they are productive and content during this period of social isolation.

The increase in mental stress is reflected in requests for help. Lifeline, for example, was hit by a 25 per cent increase in calls in March, bringing the national total to around 90,000 calls, the highest in the organisation’s fifty-six-year history. Google reported a 75 per cent increase in searches for advice on domestic violence, and Beyond Blue has seen a 60 per cent increase in contacts compared with this time last year.

Healthcare workers on the front line of the pandemic are probably under the greatest stress of all. Doctors, nurses and emergency workers already have high rates of burnout, and doctors in particular have high rates of suicide and depression. With these health professionals providing care to very ill patients and also worrying about their own safety and that of their families, Covid-19 has created new pressures.

Alerted to these increasing mental health needs, the Australian government allocated $74 million (over two years) for mental health services in the $1.1 billion package of coronavirus health funding introduced on 28 March. This included $14 million to existing help services, including Lifeline and Kids Helpline, $10 million to Beyond Blue for a dedicated coronavirus wellbeing helpline (with Medibank Private providing a further $5 million), and funds for a range of support services and communication campaigns covering frontline health workers, people receiving aged care support, young people, Indigenous Australians, pregnant women and new parents.

Another $150 million was allocated for counselling services for families caught up in, or at risk of, domestic violence. Medicare subsidies for telehealth services were expanded significantly to allow GPs, psychiatrists, psychologists and other eligible health professionals to consult with patients using telephone and video conferencing.

Despite their obvious advantages in medically underserved areas, telehealth services had not previously been widely deployed or accessed in Australia. Of the 2.4 million visits to psychiatrists in 2018–19, only 66,000 involved telehealth. Doctors and patients have responded very positively to the new arrangements. They will continue until 30 September, when a review will determine whether conditions warrant an extension. The government will be under pressure to maintain the telehealth option as part of needed mental health reforms.

Several recent studies have provided additional information about the long-term mental health impact of the coronavirus and the isolation measures. Orygen modelling commissioned by the Victorian government shows that, without action, an extra 370,000 people in the state will seek mental health treatment or be hospitalised over the next three years as a result of the pandemic, with young people disproportionately affected, and hundreds more suicides will occur.

Work by the Brain and Mind Institute, or BMI, at the University of Sydney indicates a suicide surge that could take many more lives than Covid-19. Annual suicide rates could rise dramatically — from 3000 to as many as 4500 over each of the next five years, assuming unemployment rates go as high as 15 per cent. Youth suicides will make up almost­ half of the projected increase. Hospitalisations and emergency department visits for self-harm could rise by as much as 20 per cent.

Unchecked, this would mean a generational mental health crisis in some hard-hit regions, including those affected by the collapse of tourism. Over the next five years in one such area on the NSW north coast, an estimated half a billion dollars could be lost because of a fall in productivity directly attributable to coronavirus-generated increases in mental health disorders and suicide.

To prevent this disastrous outcome, the BMI team propose an increase in specialised mental health services, to be provided by mental health GPs, psychiatrists, allied health services and community mental health services, along with technology-enabled coordinated care and outreach and enhanced contact with and support for survivors of suicide attempts. Implemented nationwide, these services would mean an estimated 2650 fewer deaths, 33,450 fewer suicide attempts and 225,800 fewer presentations to emergency departments over the next five years.

Orygen’s Patrick McGorry, the BMI’s Ian Hickie and the Australian Medical Association’s Tony Bartone sent this research to the national cabinet with a letter calling for action. “The duration and depth of the disruption to our lives [from the pandemic] is not yet known,” they wrote. “However, we do know that people living in outer urban areas, rural and regional Australians, casual workers, those recently unemployed, and older workers will most likely be affected by the social and economic impacts. We must act quickly to increase key capabilities before the surge in demand for mental health services becomes evident.”

The national cabinet and the federal government responded on 15 May with $48 million for a National Mental Health and Wellbeing Pandemic Response Plan. Of this, $2.6 million will go to the National Suicide and Self-harm Monitoring System, which was announced in the 2019–20 federal budget at a cost of $15 million over three years. Sharing a further $4.7 million will be the National Suicide Prevention Research Fund, administered by Suicide Prevention Australia, and the National Suicide Prevention Taskforce.

For outreach, $19 million will go to Primary Health Networks to deliver readily accessible services by mental health nurses, and $3.5 million to Carers Australia and Carers Gateway to provide targeted assistance and information. Another $3.5 million was allocated for health information in languages other than English, and $3.5 million for Primary Health Networks to work with Indigenous Australians. Just $10.4 million was allocated for a national mental health communication campaign, which suggests that communication is not a key priority.

For Ian Hickie, these measures don’t “seem to reach the scale or the immediacy really required now to be ready for the really significant mental health problems that we will face over the next two years.” According to Patrick McGorry, “This is a very big wall we’re trying to build and we saw a couple of bricks put in the wall [on 15 May], but when is the rest of the wall going to be built?”

The government’s plan says little about integrating mental health and substance abuse services, and provides no funding for the latter, despite polls showing that 20 per cent of Australians say they are purchasing more alcohol and 70 per cent of that group report they are consuming more alcohol than previously. The already overburdened rehabilitation system is being pushed to breaking point.

The government has also appointed its first deputy chief medical officer for mental health, Ruth Vine, to steer the federal response to the mental health implications of the coronavirus crisis. It is not clear how she will interact with the chief executive of the National Mental Health Commission, Christine Morgan. Chief medical officer Brendan Murphy told a parliamentary committee that Dr Vine would bring a clinical perspective to the work of the commission.

What else is needed to build a twenty-first-century mental health system out of a fragmented set of services that already needed a lot of work, especially in the wake of the bushfires?

Leaving aside for a moment major structural changes of the kind discussed by Jennifer Doggett in Inside Story last year, five early actions are essential. First, telehealth can only deliver its promised benefits if everyone has access, and that means tackling the digital divide and the exigencies of the National Broadband Network.

Second, all frontline healthcare workers should be offered counselling now to forestall long-term symptoms of overwork and trauma, and to ensure they can keep doing their jobs with the intensity demanded of them — something that will be even more essential if there is a resurgence of Covid-19.

Third, given the strong links between unemployment, income inequality and suicide, priority needs to be given to providing a combination of education, employment, social and health services, especially for young people. This will require greater coordination between sectors and jurisdictions, and more attention to the already-evident gaps in safety nets. Yes, this will be yet another cost to the budget, but without it the cost will be measured in lives lost.

Fourth, more must be done to tackle what the BMI’s Sebastian Rosenberg calls the missing middle — the big service gaps for the people most in need of care. That means more specialised outpatient care and multidisciplinary care for those in need.

Finally, none of this can be done without efforts to address the missing mental health workforce. Australia needs more GPs trained to better integrate mental and physical healthcare, more psychiatrists and psychologists working in the public sector and outside the major cities, more mental health nurses and more peer-support workers.

The existing gaps in the system will come under intense scrutiny in the final report of the Productivity Commission’s mental health inquiry, which goes to government next month and must then be released within twenty-five sitting days. Last October’s draft report highlighted a lack of sustained investment in mental health treatment, poor coordination and a fundamental lack of responsiveness to the needs of those most affected. It also called for more prevention and early intervention measures, particularly for children and young adults.

The findings and recommendations from this final report, along with those from the royal commission into Victoria’s mental health system, due shortly, must drive the reforms needed to ensure that Australia’s mental health system cares properly for all who need treatment. •

The post Covid-19’s second wave 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.

But perhaps they did try?

We know that Donald Trump’s economic adviser, Peter Navarro, circulated a memo on 29 January accurately predicting the stark choice faced by the United States: a strategy of aggressive containment, with immediate economic costs, or a strategy of no containment, with the deaths of perhaps a million Americans and, down the track, trillions of dollars in lost economic activity.

Navarro is the American administration’s leading China hawk. He has been pushing for the United States to “decouple” its economy from China’s and sever trade ties. His 2011 book with Greg Autry, Death by China, argues that the United States and China are on a path to armed conflict. His 2006 book, The Coming China Wars, does exactly what it says on the tin.

The trajectory of the US administration’s Covid-19 response has been consistent with a calculated effort to ensure SARS-CoV-2 spreads as widely as possible across the country. Begin by denying the seriousness of the disease; shut borders only after sufficient cases have been seeded to ensure major community spread; make a show of an urgent medical response when hospitals become overwhelmed then push to reopen the economy well before the epidemiology warrants it.

At the same time, the demonisation of China has ramped up. First came the administration’s insistence on using the term “Wuhan virus,” which was enough to scupper G20 summits and block the UN Security Council from agreeing to a resolution on the pandemic. Then came the scientifically implausible theory that the virus was engineered in the biosafety level 4 lab at the Wuhan Institute of Virology, amplified into a plank of US foreign policy by secretary of state Mike Pompeo. And then, most recently, came President Trump’s declaration that “the plague came over” from China and, in response, “We could cut off the whole relationship.”

Has the calculation been made that an American workforce with herd immunity will win the economic contest with a China having to manage containment? Or does it even matter to the administration who wins the economic contest? Is decoupling — and the division of the world into a United States bloc and a Sinosphere — the sole end?

Either way, the cost has been terrible. If this is a war between the United States and China, the body bags have already piled up. They are not being shipped back from some foreign battlefield; they are stacked in refrigerator trucks on New York backstreets or scheduled for hourly burial in rural Georgia.

The world is certainly dividing into two camps, one where containment of Covid-19 is the strategy and the other where it is not. Look at the map of daily cases per million population and the divide is sharp. Countries like Australia (currently running at 0.67) are in the group below 1. Countries with more than fifty times this rate include the United States, Britain, Russia, Belarus, Brazil and Saudi Arabia.

If this is the dividing line of a new global conflict, then Australia has already decided what side it is on. And China is on the same side.

Times of great peril require great decisions. When will the John Curtin moment arrive as we face down this pandemic? As every Australian schoolchild ought to know, when the Pacific war broke out at the end of 1941, Prime Minister Curtin turned Australia’s war effort away from Europe and to this region. “Without any inhibitions of any kind,” he declared to the Australian population, “I make it clear that Australia looks to America, free of any pangs as to our traditional links or kinship with the United Kingdom.”

This was a wrenching decision, horrifying to conservatives, but it was born of necessity. Should we have any pangs now in turning away from a belligerent “America First”?

But the Sudetenland has not yet been invaded. De-escalation is still possible.

Among the barriers to war are multilateral institutions, so it is no surprise that the United States has mounted a sustained attack on them, retreating from UNESCO, UNRWA (the agency for Palestinian refugees) and the UN Population Fund. It has crippled the World Trade Organization by refusing to allow appointments to the appeals body for resolving disputes, and this week, worn down by attrition, WTO director-general Roberto Azevêdo announced his departure a year before his term ends.

The WTO’s cardinal sin may have been to try to bring e-commerce into its purview with the goal of reconciling different views on issues like taxing data flows and preserving privacy. Alphabet (Google’s parent company), Facebook and Amazon are worth a collective US$2.6 trillion or so, around a tenth of the US economy. Even though the WTO has maintained a moratorium on tariffs on electronic transmission, the United States may reckon its advantage lies in a rules-free e-commerce world.

You’d hope that health would be exempt from this trade warfare. Historian Heidi Tworek shows in her wonderful account of the forerunner of the World Health Organization, the League of Nations Health Organization, that its persistence during the 1930s, even as international tensions rose, reflected countries’ mutual interest in rapidly sharing verified and consistent technical information on disease outbreaks.

So it is dismaying that the WHO has been a target when vested interests in conflict or its avoidance are in play. The Australian Strategic Policy Institute criticises the WHO, and through the WHO, China, but this is hardly a surprise from an organisation set up by John Howard with much of its funding from the defence department and arms manufacturers.

Can Australia play a role in deterring the weaponisation of this pandemic? It has been suggested that Australia punches above its weight in global health, but in my experience Australia is a lightweight when it comes to the real decisions that shape global health responses. Sure, Australian practitioners have a long record of making major contributions on the international stage, but a truly global Australian vision has been hampered by the old tendency to seek protection under the wing of a big power. So Australian assertiveness has been limited to the immediate region, as we see now with the government’s defence of the WHO being couched in terms of its regional impact or its tiny Pacific office.

Neither Australia nor the world will win from an escalation of conflict. In this case, conflict feeds on a false dichotomy: health or the economy. Opponents of lockdown and containment bemoan the economic losses compared with “before.” But a world without SARS-CoV-2 is the wrong counterfactual; policy choices are being made in the brute reality of a world where the virus exists. Even if governments abandon all restrictions on movement, people will still behave differently from how they behaved before Covid-19 because they want to keep themselves safe. Evidence from Google’s movement tracker showed significant reductions in US states well before lockdown orders were made. The right economic comparison is between economic activity under public health measures to minimise spread, and economic activity when people are fearful and deaths mount.

Australia is among the countries learning what a containment strategy may mean when only a tiny fraction of the population has been exposed to Covid-19. Case detection will be central, so expect testing to become ubiquitous. Fortunately, it has turned out that testing saliva is even more reliable than the awkward throat and nasal swabs that are taken now. It is not hard to imagine a near future when going to work might mean not only swiping your electronic passcard but also swiping your mouth and awaiting the virus all-clear before proceeding into the building.

Only an effective vaccine will decisively change the equation. At the pointy end of the rules-based international order is how the scramble for vaccine access will be managed. But we shouldn’t get too far ahead of ourselves: back in 2003 I was involved in an exercise to quantify demand for an HIV vaccine and establish parameters for its distribution; it was felt better to get this work done in advance of vaccine discovery, which was probably true, but here in 2020 an HIV vaccine is still as far off as ever.

While still formidable, the challenge of developing a vaccine for Covid-19 is probably less difficult than for HIV. What is beyond doubt is that demand will outstrip supply.

On this front, there have already been preliminary skirmishes. Back in March, the United States was accused of trying to buy out German company CureVac to secure access to its vaccine work, and last week the chief executive of French drugs multinational Sanofi sparked outrage when he said that the US government has “the right to the largest pre-order” of its vaccine under development “because it’s invested in taking the risk.”

At the forefront of establishing global rules for equitable vaccine access is the European Union. These rules will be considered at this week’s closely watched meeting of the World Health Assembly, the governing body of the WHO. Meanwhile a galaxy of stars in the global international order, including the serving leaders of South Africa, Pakistan, Senegal and Ghana, together with dozens of former leaders, have issued a call for “a people’s vaccine,” demanding that all vaccines, treatments and tests be patent-free, mass-produced, distributed fairly and made available to all people, in all countries, free of charge.

The tone was very different in the Rose Garden of the White House at last week’s announcement of “Operation Warp Speed,” the “America first” push for a vaccine. In a remark at once revealing and inaccurate, Trump asserted that the United States would cooperate with other countries, but not on equal terms: “We’re all working very closely together, and they’re viewing us as the leader, and we are — the relationship with other countries on solving this problem has been incredible.”

But there was no doubt that the vaccine would be for Americans only, and remarkably, for the launch of a vaccine development initiative, Trump mentioned the military at least ten times. “We have the mightiest military in the long history of humankind,” he said. “We have the best and most devoted workers ever to walk the face of the Earth. And now we’re combining all of these amazing strengths for the most aggressive vaccine project in history. There’s never been a vaccine project anywhere in history like this.”

There may be malice in this warlike posture, or it may just be braggadocio to cover up the very real difficulties of coherence and coordination from an administration elected for its skill in polarisation.

It is a strange moral universe we live in, where the assumption of systematic incompetence is more palatable than the alternative: the pure evil of a calculated jettisoning of half a million lives for the sake of a game of selective economic advancement. •

The post Which side are you on? appeared first on Inside Story.

If your encounter with this overstretched medical system proves fatal, then you’re just one more victim of the American government’s failure to react quickly and effectively to the coronavirus threat. If you’d arrived at an Australian hospital with those symptoms, on the other hand, you’d be much more likely to get undivided attention.

The difference seems obvious, and yet this clear benefit of Australia’s response to Covid-19 is often ignored in economic commentary about the trade-offs made by different countries in recent months. Some commentators assume that the cost of economic and social restrictions can be calculated simply by looking at lost production and the rise in unemployment. To get a real sense of costs, though, we need to use the full range of macroeconomic tools to compare the impact of the government’s restrictions with the counterfactual scenario of what would have happened without them.

First, it’s important to recognise that the economic fallout appears to be just as bad, and could end up being worse, in countries with fewer restrictions. The recession is a global phenomenon, and it will affect countries engaged in strong mitigation strategies (Australia and New Zealand, for example) alongside countries taking less stringent approaches (like Sweden and the United States).

In fact, it is possible, even likely, that the recession will turn out to be less severe in countries with stronger mitigation strategies. Thus, the restrictions could have relative economic benefits, not costs, in terms of output and employment.

Compounding the problem is the tendency of this commentary to take a static rather a dynamic perspective. A static trade-off uses a one-time calculation that balances, say, the value of a life against the value of a maintaining a job. It depends on a cold-hearted calculation of the statistical value of a life and the implicit side-effects of loss of employment, such as suicide and a rise in domestic violence. But it doesn’t account for the fact that the real trade-off with death is about when and how, not if, and what matters most about job losses is whether they are temporary or longer term.

What is scary about Covid-19 is that it can produce a massive spike in premature deaths and overwhelm hospital systems quickly, resulting in those further deaths that aren’t necessarily a direct result of the virus. But if a heart attack victim in New York dies because the hospital is overstretched, that death is still the result of the failure to mitigate the spread of the virus. Around the globe, hundreds of thousands of premature deaths will have huge economic consequences.

These deaths would be even more numerous if not for the fact — as macroeconomic models tell us — that people faced with a massive outbreak of a contagious disease will choose for themselves many of the precautions that governments might otherwise have imposed on them. They won’t go to restaurants; they will work from home if they can. This means that countries with less stringent restrictions will still experience a recession, but will suffer many more premature deaths in the meantime compared to countries with a strong mitigation strategy.

Effective mitigation strategies like those in Australia and New Zealand mean that activity will pick up more quickly when restrictions are eventually relaxed. More people will be willing to re-engage in spending and work than if they were warily considering their options in Wuhan, Northern Italy, Spain or New York after a much bigger death toll. The quicker pick-up will temper the severity of the recession and turn some of what might have been permanent job losses into something more temporary.

These future economic benefits, ignored in static trade-off calculations, need to be taken into account to get a complete picture of the net impact of Australia’s restrictions. Under a dynamic trade-off of the kind usually calculated by macroeconomists, the future benefits end up being large and far in excess of current costs.

The third and most important principle from macroeconomics seemingly lacking in some economic commentary is the need to use as many policy tools as there are problems needing to be solved. Economic and social restrictions are not the only tools available to governments dealing with the economic and social fallout from Covid-19. It is true that monetary policy is now severely limited by very low interest rates, but more fiscal stimulus remains a viable option.

The social costs of the restrictions are certainly very real. If lockdowns lead to higher rates of domestic violence, for instance, we can’t simply stand aside as if this is an inevitable feature of human behaviour during an economic crisis. We should use whatever educational and preventive measures we can and ramp up programs to support victims.

Importantly, if estimates of the negative social impacts of the restrictions are even partly based on past experiences in recessions, then the surest way to mitigate them is to do whatever we can to tackle the economic crisis with bridging measures and fiscal stimulus. Again, the counterfactual matters: any premature loosening of mitigation restrictions could lead to a massive outbreak, a worse economic crisis, and more social ills rather than fewer.

The trade-offs involved in responding to the Covid-19 crisis are not the ones some economists claim they are. They involve current and future costs and benefits that are relative to the cost of a recession that can’t be avoided. Tackling these trade-offs involves multiple policy tools, including fiscal policy, not just whatever restrictions our governments have imposed on economic and social activities. •

The post Covid-19 trade-offs: the full story appeared first on Inside Story.

With the Morrison government eager to be “partner of choice” for the Pacific islands, Australia and its allies have been stepping up their engagement in the region. Australia and New Zealand have been at the forefront of the response not only to Covid-19 but also to Cyclone Harold, a category-5 cyclone that traversed the region in early April causing devastation and loss of life in Solomon Islands, Vanuatu, Fiji and Tonga.

The Australian and New Zealand defence forces have been transporting relief supplies to these cyclone-affected nations. Canberra and Wellington have also funded the regional Covid-19 response through a joint team led by the World Health Organization, or WHO, and the Pacific Community, the main intergovernmental technical agency responsible for public health in the islands’ region.

The United States has committed US$27 million, mainly for its three Freely Associating States in the northern Pacific (Palau, Marshall Islands and Federated States of Micronesia). As part of a €2 billion global initiative, the European Union will also redirect €119 million towards support for coronavirus responses in the Pacific, with funding allocated to fifteen Pacific islands countries and the four European colonies in the region. France has used its military forces based in New Caledonia to transport aid to neighbouring Vanuatu and Fiji.

Despite Western concern about China’s intentions in the region, many island governments are eager to diversity their economic and diplomatic ties beyond traditional partners and have welcomed South–South solidarity from China and other nations. Over the past decade island nations have promoted the New Pacific Diplomacy through the Pacific Small Island Developing States group at the United Nations, stressing they don’t see the need to choose between old allies and new partners.

In the midst of this geopolitical tussle, many Pacific nations have been extending their trade and aid links with India, Indonesia, Korea, Cuba and Middle East states, even as they maintain longstanding ties with Japan, France and the ANZUS allies. Taiwan has also been active, seeking to retain its four remaining diplomatic allies in the Pacific — Nauru, Tuvalu, Palau and Marshall Islands — after Kiribati and Solomon Islands switched diplomatic ties from Taipei to the People’s Republic of China during 2019.

As part of this geopolitical manoeuvring, China is seeking to extend its bilateral and regional partnerships in the region during the pandemic. On 10 March, Chinese ambassadors in the islands coordinated a video conference between Pacific health ministers and China’s National Health Commission. Beijing has set up a “China–Pacific Island Countries Anti-Covid-19 Cooperation Fund” worth US$1.9 million and has shipped medical equipment and supplies to Vanuatu, Fiji, Papua New Guinea, Samoa and other island nations.

Direct support from the Chinese government is matched by initiatives from state-owned and private corporations. These companies are eager to use the current pandemic to strengthen partnerships with local governments and Pacific business networks, and to protect and advance their economic investment in infrastructure, tourism, and resources. As China analyst Graeme Smith has written in Inside Story, “Chinese capital and development finance appear to be driven primarily by market opportunities and the presence of Chinese companies on the ground in the destination country.”

Chinese corporations involved in regional infrastructure projects are now branching out to supply medical equipment. These goodwill gestures aim to burnish the image of both companies and government, at a time of growing criticism that censorship in China delayed an immediate global response to the pandemic.

One player is CCECC South Pacific Ltd, the Oceania subsidiary of the China Civil Engineering Construction Corporation, or CCECC. Established with the approval of China’s State Council in 1979, the company initially worked in Africa but now operates in nearly fifty countries, including Tonga, Solomon Islands, Tuvalu, Fiji, Vanuatu, Papua New Guinea, Cook Islands — and Australia.

Over the past decade, CCECC and other Chinese companies have built infrastructure projects in Vanuatu, often of vast dimensions and varying quality. These include a new parliament building, a national convention centre, a national sports complex, an office complex for the prime minister and a new building for the Melanesian Spearhead Group, the sub-regional organisation hosted in Port Vila. Last year, CCECC won a tender to build a new finance ministry complex. Using concessional loans from the Chinese government, CCECC is also building roads and high schools on the islands of Tanna and Malekula.

As a “good corporate citizen,” CCECC leapt at the opportunity to support Vanuatu’s preparedness for the coronavirus pandemic. The company provided twelve container houses to be used as a new isolation centre at the Vila Central Hospital, and ambassador Zhou Haicheng presented a cheque for US$100,000 to Vanuatu’s caretaker government to support efforts to prevent Covid-19 infections (as yet, there are no confirmed cases in the country).

On 11 April, a plane chartered by CCECC South Pacific Ltd delivered 4.3 tonnes of medical supplies to Vanuatu. According to CCECC, the plane unloaded “ventilators, masks, and testing kits provided by the Chinese government, some procured by the Vanuatu government and some donated from Guangdong Province and overseas Chinese communities in Vanuatu.”

The Chinese charter was still at the airport the next day, when a RAAF C-17 Globemaster flew from Amberly air force base carrying humanitarian supplies. Despite gaining approval to land from Vanuatu officials, the RAAF pilot was worried the Chinese plane was still on the narrow runway. The RAAF flew back to Australia, only returning the next day to deliver the supplies. “There is growing concern within Defence about whether the hold-up was intentional to delay the Australian plane from landing,” reported Sydney Morning Herald foreign affairs correspondent Anthony Galloway.

“We have raised our concerns with officials both in Vanuatu and in appropriate places with the Chinese government,” Australian foreign minister Marise Payne told David Speers on the ABC’s Insiders. “I don’t know whether it was deliberate or not, David. I wasn’t there.”

This diplomatic jousting over Vanuatu, played out through willing journalists, is not new. In 2018, Galloway’s predecessor as national security correspondent, David Wroe, wrote a series of stories about a purported Chinese military base on the island of Santo. Citing American and Australian security analysts, Wroe alleged that the Vanuatu government was in discussions with China about a military facility in Luganville. The claim was quickly denied by then prime minister Charlot Salwai and foreign minister Ralph Regenvanu (who had been at the Non-Aligned Movement conference in Azerbaijan, highlighting his country’s nuclear free and demilitarised status).

The following month, Wroe reported on a potential security threat from a proposed Chinese fish farm in French Polynesia. “The massive fish farm project on Hao Atoll has raised eyebrows in Canberra because it will sit next to the airport the French military previously used to carry out nuclear tests in the Pacific,” he wrote. “Concerns in Canberra focused on speculation Tianrui could seek a lease on their airport, giving Beijing a strategic foothold 11,000 kilometres into the Pacific Ocean.”

The story raised amused eyebrows in Tahiti, where government officials assured me that France would be unlikely to allow China to build a military base in its Pacific colony! Leaving the Nine-owned newspaper, Wroe went on to bigger things — he now serves as a media adviser to Foreign Minister Payne.

Under the FRANZ agreement between Australia, New Zealand and France, the defence forces of all three countries have been transporting much needed medical aid and cyclone relief to Vanuatu in the aftermath of Cyclone Harold. This cooperation enhances the reputation of the Western allies at a time when France is seeking to extend its influence in the region, tarnished by three decades of nuclear testing and the Rainbow Warrior attack. Under both Coalition and Labor governments, Canberra has signed strategic partnership agreements with Paris, perceiving France as a bulwark against Chinese influence in the islands.

But this strategic perspective is challenged by the economic interests of New Caledonia and French Polynesia, the two French dependencies that are full members of the Pacific Islands Forum. China is the largest export market for nickel ore mined in New Caledonia, while successive governments in Tahiti have sought to increase Chinese tourism and investment, as well as exports of fish, agriculture and black pearls. Speaking at a seminar on China’s Maritime Silk Road last November, French Polynesia’s president Edouard Fritch saw little difference between investors from China and other nations.

“It’s the common interest shown by private investors from China and successive French Polynesian Governments that has led to China including French Polynesia in its Silk Road initiative,” Fritch said. “We are open to Chinese private investors, just as we were to American, French, European, Samoan or New Zealand investors, in key economic sectors that open up our markets, such as tourism or aquaculture… If they are honest, they are all worthy of our friendship, whatever their nationality.”

With fifty-eight confirmed cases of Covid-19 — at a time when the France is dealing with more than 133,000 cases and 25,531 deaths — French Polynesia has been seeking medical support from China.

In another example of Chinese corporate largesse, the chief executive officer of Tahiti Nui Océan Foods, Wang Chen, has donated 10,000 masks and other medical supplies to the local government in Tahiti. After delays in obtaining personal protective equipment, or PPE, from Paris, Wang helped facilitate an Air Tahiti Nui flight from Shanghai on 6 April.

Desperate to create jobs in the outer islands, the government has been wooing Wang since December 2016, when Tahiti Nui Océan Foods lodged its proposal for the US$300 million fisheries project on Hao atoll. (Fritch’s government even presented Wang with the honorific of Commandeur dans l’ordre de Tahiti Nui in May 2018.)

Tahiti Nui Océan Foods is a subsidiary of the Chinese corporation Tianrui Group Co Ltd. Chaired by billionaire Li Liufa, the parent company operates from Ruzhou City, Henan Province, with investments in cement, foundries, tourism, mining, logistics, finance and other industries. The long-delayed initiative on Hao, however, had yet to commence operations when French Polynesia went into lockdown in response to Covid-19. Despite this, the company’s chief executive has promoted China’s interest in deeper ties.

“In China, there are also local governments which would be delighted to do something for their sister cities in French Polynesia,” says Wang. “Medical institutions have an urgent need for medical supplies, including personal protection equipment. Because of the grave situation in Europe, China has become an important hope for this region. Chinese pharmaceutical products can now be exported.”

Another Chinese player on the pandemic scene is the Jack Ma Foundation, which has been distributing medical supplies and PPE to the United States, Europe and developing countries, especially in Africa. Now, Ma is reaching out to the Pacific Islands.

The Foundation was established in December 2014 by Jack Ma, co-founder and former executive chairman of China’s Alibaba Group, a major technology and e-commerce corporation. A member of the Chinese Communist Party, the billionaire is typical of the “capitalist roaders” who have flourished in the People’s Republic since the late 1970s. Ma retired from Alibaba last year as China’s richest man and, like Bill Gates, now devotes his time to international philanthropy through his foundation.

In the first use of the newly established Pacific Humanitarian Pathway — established during a teleconference of Pacific Islands Forum foreign ministers on 7 April — the Ma Foundation has supplied tens of thousands of face masks to the islands. To avoid duplication and administrative burden on small island developing states, regional agencies want overseas donors to use this humanitarian pathway to distribute urgently needed medical supplies, equipment and technical assistance.

The Forum’s secretary-general, Dame Meg Taylor, told me that this highlights a collective response to global challenges from the eighteen member countries. Most smaller island states have so far avoided Covid-19 by working together to control their borders, she says. “If you don’t have coordination, you’re going to get every donor ringing every government saying ‘we can put together a charter for you.’ Countries are saying, if you want to bring in an aircraft, you have to abide by our protocols… It’s very clear — island leaders are very concerned about any outside people coming in to their country at all.”

Australia and New Zealand have used their own corridor to distribute assistance, although Marise Payne and NZ deputy prime minister Winston Peters joined island foreign ministers to set up the Humanitarian Pathway. Ironically, the first shipment through the regional coordinating mechanism came not from Australia but from China.

The Jack Ma Foundation flew 50,000 KN95 facial masks and 20,000 other protective masks from Shanghai to Nadi, Fiji, on 20 April. Most of the equipment will be distributed to the four Forum island countries and territories that already have confirmed cases of Covid-19: Papua New Guinea, Fiji, French Polynesia and New Caledonia. The rest will remain in stockpile for future use, with distribution managed through the joint WHO/Pacific Community regional team responding to the pandemic.

The WHO’s central coordination role in the Pacific response has complicated Australia’s diplomacy. The Morrison government, buffeted by international criticism of its climate and refugee policies, is wary of UN multilateralism. In a 2019 foreign policy lecture, Scott Morrison expressed disdain for “negative globalism” and an “unaccountable internationalist bureaucracy.”

Morrison has, for example, followed the Trump administration in refusing new funding for the Green Climate Fund, a vital source of climate adaptation finance for island states. “I don’t need to send a cheque via Geneva or New York or wherever it has to go,” he told me at last year’s Forum leaders meeting in Tuvalu. (The GCF Secretariat is actually based in Incheon, South Korea, as the prime minister should know — Australia was previously co-chair of the Fund’s, and Australian diplomat Howard Bamsey served as the secretariat’s executive director.)

Following Donald Trump’s decision to suspend funding to the WHO, China responded with a further grant of US$30 million to the UN agency. Now Australia has echoed Trump’s call for an international review of the WHO. Foreign Minister Payne has also issued a public call for a review of the pandemic, even before other OECD countries had agreed to the proposal. The subsequent public jousting with China’s ambassador to Australia, Cheng Jinye, gives lie to the notion that “we’re all in this together.”

Even as the US and Australian governments have criticised China’s purported influence over the UN agency, the important role of the WHO office in the Pacific has been acknowledged by Marise Payne. “Australia shares some of the concerns of the United States in relation to the operation of the World Health Organisation,” she said on Insiders. “But importantly, for us, particularly in the Indo-Pacific, in the Pacific itself and in Southeast Asia, we do some extremely valuable work with the World Health Organization. They rolled out in early February a regional impact process for the coronavirus pandemic in the Pacific, which both Australia and New Zealand have funded. Their multilateral impact in the Pacific is very significant.”

As with climate policy, the current brawl over the WHO highlights how Australia’s global strategic interests and alliance with the United States can come into conflict with the realities of the Pacific islands. But at a time of geopolitical change and rising US-China tension, many of Australia’s neighbours are still eager to work with partners from all corners of the globe. As Dame Meg says: “I think our island countries want to help themselves. It’s like the climate issue — the voice of the Pacific needs to be heard.” •

The post Geopolitics meets pandemic in the Pacific appeared first on Inside Story.

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. •

The post How Covid-19 is reshaping the way we see healthcare appeared first on Inside Story.