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. •

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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. •

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The post Living toughly appeared first on Inside Story.

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.

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

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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. •

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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.

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.

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.

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. •

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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.

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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.

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In 1984 the high-profile businessman and Liberal Party identity John Elliott, president of the Carlton Football Club, led an initiative to form a breakaway league. The VFL responded by changing its governance structure and redoubling its efforts to corporatise the sport. Pressure mounted to close grounds and merge clubs, or to move some clubs interstate to tap into new “‘markets.” Fitzroy — a team based in an old but now gentrifying inner suburb — was still enjoying fair success on the field in the mid 1980s but only narrowly averted an attempt to move it to Brisbane in 1986 (a move that would eventually be forced in 1996).

Efforts to merge or move clubs provoked lively grassroots resistance on the part of supporters for whom the Saturday afternoon ritual was a link not only with a loved place — the home ground — but also with a way of life pursued by their parents and grandparents. The defiant and successful movement in late 1989 to save the struggling western suburban Footscray from a merger with Fitzroy drew on loyalties to class, club and community, a sense that others looked down on the western suburbs, a feeling that malign forces were trying to destroy something precious and loved.

For those who fought to save Footscray, one of the problems was the VFL’s obsession with creating a national league, one that would extend the code — or “product” — to Sydney and Brisbane as well as encompass the major football-playing states of South Australia and Western Australia. By 1991 what was now called the Australian Football League included clubs from all five mainland states.

For a time it seemed that rich men would become not merely the presidents but also the owners of teams. The major experiment of this kind involved the Sydney Swans, a club that emerged from the northward relocation of the declining South Melbourne team in 1981. The effort to place the Swans on a secure financial base and promote the game to a Sydney audience flushed out “medical entrepreneur” Dr Geoffrey Edelsten, then unfamiliar to most members of the public but better known to the Australian Taxation Office.

Since graduating in medicine from Melbourne University, Edelsten had enjoyed a colourful if rather chequered career as a medico, businessman and playboy. He had produced pop records, owned a nightclub, established his own flying doctor service, run health studios, set up a high-tech pathology laboratory in the United States, and offered a Family Health Plan in Sydney — which looked to police rather like a medical insurance business minus the necessary licence. He had even sponsored the Bluebirds, a troupe of dancing girls whose presence at Carlton home games was intended to add an American-style razzamatazz and sexiness.

By the mid 1980s — now grey-haired but still with an eye for female talent — he had married a professional model, Leanne, more than twenty years his junior. Edelsten was now best known for operating a chain of Sydney surgeries that, in their decor and design, had more in common with brothels than most people’s image of a humble general practitioner’s rooms. But then Edelsten was no humble general practitioner, even if all his patients needed to do to enjoy the luxurious facilities provided by “the Hugh Hefner of medicine” was to flash their green and gold Medicare card.

“His surgeries are decked out in gold, with salmon pink velvet couches, enormous chandeliers and mink-covered examination tables,” reported one journalist. “Gold-clad hostesses and a small robot offer refreshments and educational advice to patients, who are told that if they wait more than ten minutes to be attended to they are entitled to a free Instant Lottery ticket.” The surgeries also came with white baby grand pianos; a pianist was sometimes paid to entertain patients while they waited.

The glitz of the surgeries was matched by the Edelstens’ private life. There was the $6 million home in Dural and luxury cars with numberplates that said “Macho,” “Spunky” and “Groovy.” And there were Edelsten’s gifts to Leanne, which supposedly included a pink helicopter — that it was pink Edelsten always denied, but many people swear that they saw it — and, the Daily Telegraph reported, “a $100,000 pink Italian sports car lined with white mink.”

In late July 1985 the VFL agreed to award the licence for the Swans to Edelsten in preference to the bid of another businessman, Basil Sellers (a man “of much more conservative bearing,” according to the Canberra Times). The league needed to get the Swans noticed in a tough market, and Edelsten appeared to be just the kind of showman capable of helping it out. Indeed, the syndicate to which he belonged played up the glamour as a means of distinguishing itself from the other bidders. It promoted the Edelstens as embodying Sydney’s colour, playfulness and hedonism in contrast with the sober restraint of Melbourne. Edelsten exuded flamboyance, wealth and success, and Leanne — present when her husband learned that his Swans bid had been successful and wearing, according to one report, “a sequined white jumper, red leather pants and wet-look white thigh-length boots” — was central to his image.

Media reports said the price was $6.3 million, a figure that casual observers assumed had been carved out of a much greater fortune, but it soon became clear that the deal was a rather more tangled one. Edelsten eventually handed over about $3 million, mainly other people’s money. It looked increasingly as if he was really a frontman for other interests, but there was no denying his ability to attract notice. He was helped by a spectacular, long-maned, blond full-forward named Warwick Capper, who wore striking white boots and shorts even tighter and more revealing than the usual skimpy kind. He, too, briefly became an image of Sydney spunkiness and flamboyance.

Edelsten’s association with the Swans gave his surgeries publicity that allowed him to evade the prohibition on doctors advertising their services, but it was the doctor’s business interests outside football that caused him problems soon after the award of the licence. A Labor senator, George Georges, alleged under parliamentary privilege that Edelsten was the “Dr X” named in a parliamentary committee report as being investigated for medical fraud. Edelsten took out a full-page advertisement in the Sydney Morning Herald declaring his innocence. An exposé of Edelsten’s business methods in the satirical magazine Matilda, which imputed various forms of lurid criminality, added further damage and provoked a lawsuit.

Worse followed: Edelsten soon stood accused of having hired the notorious hit man Christopher Dale Flannery to assault a patient who had given him trouble. He had already stood aside as Swans chairman but still had a long way to fall. He subsequently became bankrupt, divorced, and was struck off the medical register and sent to prison. And as the 1980s passed into mythology, his and Leanne’s lifestyle was seen to epitomise the era’s excesses. •

This article draws on The Eighties: The Decade That Transformed Australia (Black Inc., 2015).

The post Dr X meets his end 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. •

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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. •

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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.

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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.

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.

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. •

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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.

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. •

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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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.

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.

This information overload provides fertile ground for misinformation and conspiracy theorists. An unholy alliance is emerging of anti-vaxxers, China hawks and gun-toting libertarians, ready to seduce the credulous and the disaffected. Marlon Brando’s Johnny in The Wild One said it best: asked “What are you rebelling against?” he replied, “Whadda you got?”

Some dedicated souls are refuting the lies, piece by piece. But observing the old internet adage, don’t feed the trolls, I prefer to slip down the more orthodox rabbit holes.

One driver of this truly revolutionary explosion of scientific literature has been the changing ecosystem of academic publication. When journals as printed and bound artefacts lost their salience, their publishers moved online, relying on legacy reputations buttressed by prestigious editorial boards. It didn’t take long for pay-to-publish outfits to emerge, recognising there was money to be made by exploiting the publishing imperative among the oversupply of university staff. Distinctions between legitimate and predatory publishers became increasingly hard to navigate.

But in the last few years the environment has changed again. Bibliometric and altmetric measures of citations and impact, combined with legitimate publishers’ databases, are increasingly used to determine access to research funding and academic promotion.

If peer-reviewed and quality-controlled journals are the high-end retail outlets for these research products, the warehouses are the preprint servers. In the natural sciences, the arXiv (pronounced archive) has been around for thirty years. In other fields, these repositories are much newer. MedRxiv, where much of the Covid-19 literature has appeared, was launched less than a year ago. With its sister repository, bioRxiv, it lists 3172 Covid-19 articles, a figure that’s growing rapidly: a quick count shows twenty-nine articles added on 10 May and forty-three the day before.

These preprint servers are not a complete free-for-all. They are hosted by reputable institutions and are moderated, at least to a degree, and sorted into relevant subject categories. But the articles are posted before peer review, and many will never make it through that process. The urgency of slowing the Covid-19 epidemic and staving off deaths makes it very tempting to scour these servers for the latest research, but that comes with the risk of spurious results and junk science.

Artificial intelligence, or AI, proposes a way of identifying the best of this research. Scite.ai is a new tool powered by machine learning that trawls through mountains of scientific literature and not only counts the number of citations in other papers but also tracks whether subsequent mentions support or contradict the original paper. Some papers are widely cited because they are the best example of what not to do — Scite.ai enables a rapid sifting of right from wrong.

Galen and Avicenna would have recognised trial and error as basic to the scientific method. AI makes possible a major shift in this paradigm: for example, chemists can now use retrosynthesis methods to deconstruct and then reconstruct molecules, and potentially engineer drugs with very precise targets — blocking virus replication, for example.

The contrast couldn’t be greater with the fabled serendipitous breakthrough that dominates how we imagine drug discovery. (“On the morning of Friday 28 September 1928 Alexander Fleming finds that the mould growing on a petri dish accidentally left on a shelf kills bacteria, and so penicillin is born.”) AI wants to do away with this image altogether. The slightly ominous-sounding BenevolentAI is a case in point: setting its algorithms loose on a vast database of potential drugs, it pinpoints arthritis drug baricitinib as the most promising compound to combat SARS-CoV-2, and propels it into human trials.

The same shift is happening in vaccine development. Ever since Edward Jenner discovered that a dab of cowpox could be used to fight smallpox, vaccination has worked with two basic strategies: using either a killed version of the virus in question or live virus altered enough to cause only the immune reaction and not the full-blown disease.

For SARS-CoV-2, new techniques are in play to engineer vaccines from first principles, creating a vaccine that inserts itself into a particular site in the molecular pathway to disrupt the virus’s colonisation of the host DNA.

In the early AIDS days, gene-based techniques were in their infancy. I vividly remember a conversation in 1993 with a friend who, with a mix of hope and desperation, was betting his last throw of the dice on gene-splicing techniques he had heard about from Canada. He never got to try them.

At the time, antibody tests using a pinprick of blood were the stalwarts of HIV diagnosis. PCR assays, which amplify genetic fragments from a sample, were useful for confirming borderline cases, but they were cumbersome and prohibitively expensive.

That world has been turned on its head. PCR and other gene-amplification methods are the readily available go-to options for a test. Once the virus was isolated it could be plugged into the machines and reliable tests set up in a matter of days, as Victoria showed. Antibody testing has proved much more difficult, partly because we are still learning about the nature and timing of the antibody response to Covid-19.

To be useful, diagnostic tests need to meet two thresholds that point in different directions: sensitivity, when the test is fine-tuned enough to detect the virus if it is there; and specificity, when the test reacts to the virus in question and not to similar signals. Insufficient sensitivity will produce false negative results; insufficient specificity will produce false positives. Fast and dodgy operators thought they could bang together an antibody test for Covid-19 and rush it to market, but getting that balance right turned out to be much trickier than expected.

Remarkably, CRISPR technology — the gene-splicing technique that enables a small slice of DNA to be cut out and replaced — is coming to the rescue. Thirty years ago this was the very definition of cutting-edge science. Today, a CRISPR-based test stands ready to transform Covid-19 diagnostics, with the promise of a test simple and cheap enough for home use.

When the human genome was first fully described after a thirteen-year, multimillion-dollar project, it was hailed as the dawn of a new era of precision medicine. But gene therapies didn’t start rolling out the door, and the hype faded. Maybe it was a slow burn.

Covid-19 is perhaps the first pandemic with a genomic response: from epidemiology to diagnostics, to therapeutics, to vaccines, the virus’s genome has been front and centre. This pandemic is the crucible in which these genetically based and rationally designed approaches fuelled by AI will prove their mettle — or not.

For an alternative to these ponderings on science, here are a couple of great reads from the last few days.

Rutger Bregman’s new book Humankind is out in English next week, and as a teaser he offers the uplifting tale of a real-world Lord of the Flies in which a group of shipwrecked boys descended not into chaos but rather into amiable cooperation.

One of the smartest of development economists, Dani Rodrik, has considered what a better globalisation could look like. When Australia has not been too busy being Washington’s poodle, it has been a leading advocate of a rules-based global order. Those rules will need to be redrawn in a post-Covid world, and Rodrik provides a good pointer. •

The post The first genomic pandemic 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.

Under border restriction regulations imposed in Queensland since early February, Sladen was summoned to appear in court, where, on 6 May 1919, he was sentenced to a month’s imprisonment. Across two borders to the south, the Victorian branch of the Australian Natives Association protested against this treatment of a returned soldier; Sladen nevertheless served out his time at Brisbane’s Boggo Road Gaol.

Sladen’s service to his country hadn’t counted for much for the sentencing magistrate, who believed the higher duty of deterring others weighed heavily at a time when the “public health was so gravely concerned.” In fact, Magistrate Dean would have a busy month dealing with cases involving breaches of quarantine, handing out his severest sentence, of three months, to a thirty-eight-year-old bookmaker who had tried to slip across the border at Coolangatta with his two clerks. In that case, the evidence appeared to show an intention to evade quarantine controls at Wallangarra, the centre of Queensland’s border control efforts.

The quarantine and isolation measures introduced during the Spanish flu were resented most famously by rebellious soldiers, and inconsistencies in rules across the country and disunity among the states and the Commonwealth didn’t help. Indecision by the quarantine and port authorities lay behind an alleged mutiny by returning soldiers on an overcrowded vessel, the Somali, in Adelaide. The mutiny might have consisted of little more than threats by soldiers to row themselves ashore, but it resulted in the arrest and court martial of the federal Labor member for Adelaide, Edwin “Gunner” Yates. Yates’s trial was no mere formality, but his able young counsel, Alf Foster, couldn’t save him from conviction and sixty days in detention.

In spite of cross-border transgressions and unhappy returning soldiers, the necessity of quarantine was largely accepted at the time. With a lower death rate than in neighbouring New Zealand, and well short of the catastrophic eruptions in places like India, Australia was relatively fortunate. Geographic isolation, assisted by maritime quarantine and some state-imposed restrictions, undoubtedly helped save lives.

Epidemics have patterns — they fall unevenly on populations, on regions and over time. Australia’s epidemic was no different. Having arrived late here, infections peaked more than a year after the virus had washed through most other continents in the second half of 1918. Instead, “Spanish flu” was a 1919 experience for Australia.

The epidemic’s sudden arrival in Melbourne and Sydney in January touched off a rapid increase in deaths over the next three months. Every state subsequently experienced two waves, with a short intervening period. But the first impact was spread over a number of months in different states.

In spite of the somewhat fractious political climate, all states came to be declared as quarantine areas, beginning with New South Wales and Victoria in late January. South Australia’s declaration came a week later, Queensland not until May, Western Australia in June and Tasmania, the last, in August. This administrative history maps onto the mortality calendar in 1919, with a first peak in April, a short period of decline through May and then the greater impact in the middle of the Australian winter in July. By the end of the year few deaths were being recorded.

New South Wales was the state most affected, not only in absolute numbers but per head of population. Tasmania — conventionally regarded as having survived best because of its maritime isolation — had a mortality rate no different from that of South Australia. All states except Victoria closed their borders at one time or another, despite the view of the Commonwealth director of quarantine’s view that such closures would be futile, impossible to monitor and potentially dangerous because they involved ill-equipped quarantine facilities at rural outposts like Wallangarra.

Queensland’s determination to close its borders and prosecute transgressors like Frederick Sladen didn’t save it from a mortality rate much the same as Western Australia, though still below that of Victoria and New South Wales. The states mostly relied on light policing, with only Queensland appearing to have resorted to exemplary imprisonment of a few. In Sydney, zealous policing of mask regulations in early February led to hundreds of fines.

Trouble would come later for a state government that found it had exceeded its powers, however. In November the High Court upheld an appeal by hoteliers against prosecutions for breaching trading restrictions in New South Wales. And in December a Balmain doctor who had been committed for trial in February after breaching mask regulations was awarded £150 damages by a jury that agreed he had been falsely imprisoned by a Sydney magistrate. The doctor’s lawyer was future High Court judge and Labor leader, H.V. Evatt. In the end, the states’ regulatory powers remained contentious, as did the level of police enforcement needed to protect the community.

New South Wales eased its restrictions after April, only to find the epidemic return more fiercely in winter. The postponed Peace Ball at Sydney Town Hall in early June was subsequently blamed in the press and by public health authorities for adding to the spread of infection.

Just as national figures disguise a different story in each state, so were the epidemic’s effects different across the population generally. The influenza of 1919 especially affected young men up to the age of forty, and even more so if they were working class-men living in the poorer and inner-city suburbs of Sydney. In Queensland, the greatest impact fell on Aborigines. The chief protector’s annual report for 1919 revealed that at least 298 Aboriginal people had died, making up more than a quarter of the state’s deaths from influenza and constituting a death rate up to nine times that of the general population. Western Australia’s protection regime appears to have prevented significant Aboriginal mortality in that state, but in Queensland Aboriginal workers who became sick on farms and stations were sent back to their home settlements only to pass on the virulent infection.

The differences in global, medical and political context over the span of the past century raise questions about whether we can learn much from the Spanish flu pandemic. Much was changed by its impact — in stimulus to medical research that eventually uncovered its cause to be a virus rather than bacterial, and in the development of medical and hospital systems to better cope with infectious diseases — so there’s some point in revisiting the evidence to estimate what accelerated or limited its spread. In particular, though, the fact that all states, and especially New South Wales, experienced a more damaging second phase after restrictions were lifted is an ominous reminder of the risks of impatience in the face of an epidemics. •

The post Collateral damage appeared first on Inside Story.

What has been learned and how is that knowledge being used?

The story of the origin of the coronavirus pandemic is now fixed in the public mind. In late 2019, it goes, a new virus was generated as wild animals (pangolins are often invoked) and humans came together in the Wuhan wet market.

In reality, we don’t know exactly what happened — and it is important to trace the genesis of this virus because it’s the key to stopping the next pandemic. It now seems most likely that the coronavirus originated in bats, which are natural reservoirs for viruses. But we still don’t know which species served as an intermediate host before the virus moved to humans. Bats were where the 2002 SARS outbreak started, moving to civets before infecting humans. As the detection of the new virus in pets and a tiger in the Bronx zoo shows, coronaviruses like SARS-CoV-2 are circulating all the time in the animal kingdom.

There is definitely some sort of connection to the Wuhan wet market, which was the first epicentre of the pandemic, but the first recognised case in Wuhan had no clear link and pangolins are unlikely to be involved.

How and when the virus arrived in the United States is also unknown. Recently released evidence overturns the idea that the first infections were in a Washington state nursing home and the first coronavirus-related death in Seattle on 29 February, shifting the timeline of the virus’s spread to weeks earlier. Two Californians who died in their homes in early to mid February were infected, which means the virus was circulating in California for at least a month before it was detected in Washington state.

New York City announced its first confirmed Covid-19 case on 1 March, but modelling suggests nearly 11,000 people in the city could already have been infected. Moreover, genetic analyses show that most infections in New York came from multiple locations in Europe rather than directly from China. No one then was paying attention to the planes flying into New York from these locations.

This undercover start — and subsequent difficulties in containing it in countries like the United States, Italy and Spain — reflects Covid-19’s long and variable incubation period (the time between exposure and first symptoms is typically five to six days but may range from two to fourteen days) and the fact that some infected people have only very mild symptoms or none at all. Recent studies suggest about 40 per cent of those infected are “silent carriers,” although one study from China put this as high as 80 per cent.

Children and young, healthy people seem more likely to be asymptomatic, but it is unclear if this also means they are not infectious. French researchers found one child who was simultaneously infected with coronavirus, influenza virus and the common cold. Both of his siblings caught the latter two viruses, but the research subject didn’t pass coronavirus on to either of them, nor to any of the other 172 people he had contact with.

A small study by the National Centre for Immunisation Research and Surveillance came to the same conclusion — that children are unlikely to transmit coronavirus between each other or to adults. This report is being cited by the federal government as it advocates the reopening of schools.

Infectious disease experts are still trying to understand this variability in who gets infected and who shows symptoms, but the lesson learned is that widespread testing is essential to understand the full extent of infection in the community.

The SARS-CoV-2 virus is most commonly found in the upper respiratory tract and in fluids from the lungs. It spreads primarily through infected droplets generated by coughing and sneezing, or when hands touch surfaces or objects contaminated by these droplets and particles. Some studies have suggested that aerosol transmission is plausible, though others dispute this.

It is not clear whether pregnant women can pass the infection on to their babies. While several cases of newborns with coronavirus have been reported, no traces of the coronavirus have yet been found in the placenta or the umbilical cord, making it unlikely that a mother can infect her child while it is still in the womb. This could change as more information becomes available.

Viable, infectious SARS-CoV-2 has also been isolated from blood, urine, and faeces. It is not yet known whether other non-respiratory body fluids from an infected person — vomit, breast milk or semen, for instance — can be sources of infectious SARS-CoV-2.

Infectivity is measured by the reproduction number (the number of people an infected person will pass the illness to). For SARS-CoV-2 this is 2.0 to 2.6 – higher than the flu (1) but considerably less than measles (15). Scientists don’t know how many virus particles of SARS-CoV-2 are needed to trigger infection, and the extent to which viral load is an indicator of the severity of disease is unclear. Two studies in the Lancet reported that people who develop more severe pneumonia had, on average, higher viral loads when they were first admitted to hospital; but another study found that some asymptomatic patients had similar viral loads to patients with Covid-19 symptoms.

The virus enters the body through the mucous membranes of the face (eyes, nose and mouth), which provide a direct pathway to the throat and lungs. The path from the point of infection varies enormously and is determined by each individual’s immune system.

About 80 per cent of people with Covid-19 recover without needing any specialist treatment. But sometimes, even in otherwise healthy patients, the immune response is excessive or prolonged and causes what’s known as a “cytokine storm.” In these cases, the inflammation and organ damage can be fatal.

The most common cause of death in people with Covid-19 is acute respiratory distress syndrome, or ARDS, the result of a build-up of fluid in the lungs. Elderly people and those with chronic lung disorders are more likely to develop ARDS. A predominant theory is that these patients have increased levels of angiotensin converting enzyme 2, or ACE2, which acts as a receptor for the virus. There is confusion about whether the infection is amplified by a class of drugs used to treat hypertension that affect ACE2 levels and are often taken by patients most susceptible to coronavirus.

Some evidence also suggests that in severe cases, the virus may enter the brain through the olfactory nerve in the nose and damage that part of the brain that controls breathing.

One of the most shocking aspects of this pandemic is how people become so ill so quickly. Clinicians are just beginning to recognise that Covid-19 pneumonia initially causes a form of oxygen deprivation called “silent hypoxia” because it is insidious and hard to detect, and patients don’t feel short of breath. By the time their situation is recognised, patients’ oxygen levels are seriously compromised. Then the only treatment is mechanically to take over the patient’s breathing. Simple monitoring of blood oxygen levels can prevent this.

A striking feature of Covid-19 is that it disproportionately affects males. A meta-analysis of 206,128 cases around the world found that, although the number of infections was roughly equal between sexes, men were more than twice as likely to get so sick they needed intensive care and about 60 per cent more likely to die.

Two previous emerging coronavirus diseases, SARS and MERS, also disproportionately affected men, as, to a lesser extent, does influenza. This may be related to the very different immune systems of men and women and/or hormonal differences. Some have proposed a role for smoking, as smoking rates are universally higher in men. Another possibility is that men — especially older men — are in generally worse health than women. When the authors of a New York study factored prior health status into their analysis, they found that sex was no longer one of the main risk factors for severe Covid-19.

A prime risk factor for severe complications from Covid-19 is obesity. Although people with obesity frequently have other medical problems (such as heart disease and diabetes), studies indicate that obesity in and of itself is exceeded only by age as the most significant risk factor — and, surprisingly, is more important than asthma and other chronic respiratory conditions — for hospitalisation. Young adults with obesity appear to be at particular risk.

It is postulated that in coronavirus-infected patients with obesity, there is greater inflammation of adipose tissue, the fatty layer under the skin and around internal organs, and this contributes to immune activation, an enhanced cytokine storm, and increased virus shedding. There is a view that obese people shed virus for longer and that their quarantine should therefore be longer.

A shocking aspect is the racial disparities seen in coronavirus hospitalisations and deaths, especially obvious in the United States and Britain. Data from the US Centers for Disease Control and Prevention show that the rate of recorded Covid-19 deaths among African Americans (92.3 deaths per 100,000 population) and Hispanics/Latinos (74.3) were substantially higher than for white (45.2) or Asian (34.5) Americans.

Reports from cities including Chicago, New York and New Orleans indicate even greater racial disparities in death rates. A Washington Post headline described the virus “ravaging one of the country’s wealthiest black counties.” The situation appears to be worse for Native Americans living on tribal lands. Of the first 2249 patients with confirmed Covid-19 in Britain, 35 per cent were non-white, much higher than the proportion of non-white people in the population. Sadly, the fate of many patients, especially people of colour, is sealed by pre-existing social determinants of health and established racial inequalities.

While there is growing understanding of the risk factors and causative mechanisms of Covid-19 disease, this has yet to deliver a vaccine to prevent it or pharmaceutical treatments for the pneumonia it causes.

In desperate bids to find these treatments, researchers, clinicians and pharmaceutical companies around the globe have launched a raft of studies and clinical trials investigating experimental drugs, a decades-old malaria medicine, a veterinary drug that also kills head lice and the parasites that cause river blindness, and cutting-edge therapies that have worked for other conditions such as HIV and rheumatoid arthritis.

The value of this work is undermined by a lack of national, let alone international, strategies, leading to overlapping efforts and an array of small-scale trials that will not lead to definitive answers. No agreements have been reached about how to prioritise efforts, which data to collect and how to share findings to get answers faster. It’s been described by one observer as “chaotic.” A key hedge to the many trials is that there is no recognised “standard of care” against which to compare the drugs being studied.

Such results as have been delivered to date are, not surprisingly, either negative or inconclusive. Regulators have warned about the risks of the malaria drug hydroxychloroquine (much promoted by Donald Trump), and early reports from clinical trials of this drug and Remdesivir (a failed candidate for treating Ebola) have been damning, although other studies are still under way. Published results from a trial of the combined antiretroviral drug lopinavir/ritonavir also showed no improvement in clinical outcomes. A study of the head lice drug ivermectin is proceeding despite warnings that the dosage needed to kill coronavirus is up to one hundred times higher than approved doses.

The real quest is for a vaccine to prevent infection. Many vaccine prospects are being explored using a wide range of research approaches. Fortunately, the international cooperation has been much greater than for pharmaceuticals, as evidenced by the work of the Coalition for Epidemic Preparedness Innovations. One survey of the Covid-19 vaccine development landscape found 115 vaccine candidates. Of the seventy-eight confirmed active projects, seventy-three are currently at exploratory or preclinical stages and only a handful have moved into clinical development and testing. Hanging hopes on the development and large-scale production of a safe and effective vaccine within the next few years is an exercise in unbounded optimism.

As a way of buying time, researchers in four countries will start a clinical trial of an unorthodox approach testing the century-old BCG vaccine, used against tuberculosis, to see if it can generate a non-specific immune response that will fight off the coronavirus. Options for repurposing other vaccines are also being explored.

Most research funding is being spent on finding a vaccine and effective drugs. That effort is vital, but it must be accompanied by research on how to target and improve the non-drug interventions that are the only effective interventions so far.

The only established treatment for Covid-19 is supportive — basically the provision of oxygen via masks, respirators, ventilators and, in extreme cases, extracorporeal membrane oxygenation to help maintain high oxygen levels until patients’ lungs have recovered sufficiently for them to function normally.

These latter two treatments are resource-intensive and expensive forms of life support, with the potential for causing severe complications including infection and haemorrhage. Ventilating patients with Covid-19 seems to drive the infection deeper into the lungs and saves few lives. Avoiding the use of a ventilator is better for both patients and the healthcare system, so there is an urgent need for controlled clinical trials of ventilation versus non-invasive oxygen therapy in these patients.

In terms of prevention, the only approaches currently available require physical isolation, hand hygiene and protective equipment like masks. These interventions have been assessed by only a handful of studies, most of which have been assessed as of low quality or small sample size.

Work is under way to understand if the levels of immunity in individuals and the population after infection are protective, and how long that immunity could last. With no widespread inherent immunity to a new virus like SARS-CoV-2, scientists are starting from ground zero.

Doctors examining the blood of patients recovering from a Covid-19 infection are finding that fairly high levels of neutralising antibodies are made by the immune system. These antibodies coat an invading virus at specific points on its surface, blocking its ability to break into cells and thus conferring immunity. Most virologists believe that immunity against SARS-CoV-2 will last only a year or two, in line with other coronaviruses that infect humans. That means that even if most people do eventually become exposed to the virus, it is still likely to become endemic, with seasonal peaks of infection.

Current antibody tests, which show who has been infected, are often inaccurate, and it is not clear whether a positive result signals immunity to the coronavirus. The World Health Organization has warned against relying on these tests for policy decisions such as the introduction of “immunity passports.

It is possible that antibodies can be turned into therapies. Plasma containing the antibodies from recovered patients is transfused to gravely ill patients in an experimental treatment known as convalescent plasma therapy. Early results from a small number of Chinese patients, published in late March, were promising. Doctors have been using convalescent plasma transfusions to help patients fight diseases as far back as the Spanish flu of 1918. More recently, the procedure has been used in patients with SARS, Ebola, and H1N1.

Both vaccine development and plasma therapy depend on the virus not mutating in a way that modifies the shape of its antigens. Several studies have also established the relative stability to date of the SARS-CoV-2 genome, perhaps because the virus is encountering few immune hosts who could halt its spread.

Researchers have shown that two major strains of SARS-CoV-2 now exist. The newer and more aggressive L type accounts for about 70 per cent of the analysed cases, while the rest are linked to the older S type version. The mutations don’t seem to have affected the S1 spike protein, which is the antigen most people are targeting for vaccine production. But another study from China suggests that the virus’s ability to mutate has been vastly underestimated, providing laboratory evidence that certain mutations could create strains deadlier than others. Much more research is needed in this area, including monitoring virus samples from different locations over time to track mutations.

Finally, what do Covid-19 recoveries look like, and what are we to make of the host of side effects that are now appearing? On these questions, evidence is thin.

The recovery path for Covid-19 patients is very slow. Most cases recover within three weeks, but they can take much longer and be much more complicated and less linear for the sickest patients. Weaning patients off ventilators can take several weeks, and patients who have been in intensive care can experience delirium and symptoms of post-traumatic stress syndrome.

Once thought to be a pathogen that primarily attacks the lungs, the virus now seems to inflict long-lasting damage on many of the body’s organs. Reports are coming in of kidney damage requiring dialysis; strokes, even in young people who had only mild symptoms; Guillain–Barré syndrome, blood-clotting complications; neurological problems; and liver and intestinal damage. Doctors in Britain, Italy and Spain have been warned to look out for an inflammatory condition (perhaps the rare Kawasaki disease) in children, which is possibly linked to coronavirus. For many patients, surviving Covid-19 means a long road back to health.

How the pandemic ends will depend on medical advances still to come and perhaps yet to be predicted. In the interim, for communities and nations, surviving depends on individual behaviours and compliance with evidence-based guidelines. •

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Two things stick in my mind from that meeting. One was the call by economist Jeffrey Sachs to imagine what an AIDS response would look like if no resource constraints existed. At the time, estimates of the funds needed to tackle AIDS in low- and middle-income countries diverged wildly — the World Bank thought US$300 million was as much as countries could absorb; the price tag from some activist scientists went as high as US$40 billion. To cut through this fog, Sachs insisted that the first task was to specify what was needed without thinking about the cost, and only then make estimates of the necessary outlays.

The second notable presentation was by leading British epidemiologist Sir Roy Anderson. Epidemics always proceed in waves, he advised, with the first wave peaking as the most susceptible are affected. Thereafter, the overall curve may decline but it is actually made up of innumerable individual waves, as the virus colonises and passes through a new group or territory. The crucial question, therefore, is the steepness of the decline on the other side of the first peak, and how much the curve stays down as the further waves hit.

Fast-forward to December 2010, when UNAIDS introduced a new strategy and a new slogan: getting to zero. It called for zero new HIV infections, zero AIDS-related deaths and zero discrimination. The germ of this idea came from Laurie Garrett, world-renowned oracle of emerging pandemics. Why not put a great big zero on your next report, she suggested to UNAIDS. The slogan struck the right note, and proved very popular at country level. (It sometimes got lost in translation, though: I remember receiving a fancy document holder from a national AIDS authority proudly emblazoned with the message “Getting Zero.”)

The new goal inaugurated a debate about “the end of AIDS” that continues to be controversial, with some people — including Piot, post-UNAIDS — arguing that the goal remains so distant it is misleading to raise the hope. It also focused much closer attention on the concept of disease elimination.

Epidemic management has a hierarchy of terms. At one end is mitigation, when efforts are made to reduce the worst effects of the disease without any hope of modifying its spread. Then there is control or suppression, when the drivers of the disease are sufficiently understood and the capacity exists to manage its spread, slowly bringing the number of new cases under control. Then there is elimination, when the disease is so tightly controlled in a given territory that health authorities can assert with confidence that new cases of the disease are not present. And finally there is eradication, when the virus or pathogen that causes the disease dies out because it has no human hosts — a feat achieved with smallpox and almost with polio. (Getting rid of the last hundred cases takes about as much effort as the previous million.)

Malaria provides a good example of elimination efforts, and island nations have been ideal test cases. In 1867, a few years after the disease was introduced into Mauritius, a virulent epidemic killed one-in-eight islanders. Control efforts and quinine distribution gradually limited its spread, and a major elimination campaign from 1948 to 1951 reduced cases by more than 95 per cent. Eventually, in 1968, the last local case was detected, and WHO certified Mauritius malaria-free in 1973.

But when Cyclone Gervaise devastated the island in 1975, the combination of new mosquito habitats and an influx of reconstruction workers allowed a new malaria epidemic to take hold, peaking in 1982. The elimination effort began all over again, with the last case of indigenous malaria recorded in 1997. Even now, Mauritius maintains constant vigilance, with a multimillion-dollar program of surveillance, incoming passenger screening, and obligations on residents to participate in environmental management.

Eliminating malaria with a combination of vector control, effective treatment and cheap prophylaxis is a doddle compared with the task we face given our current knowledge of Covid-19 (and the fact that no fully effective malaria vaccine exists even after generations of effort gives pause for thought). That history, and the history of other epidemic responses, suggests that health authorities in Australia and New Zealand are right to be cautious about declaring a goal of elimination. They know that even were elimination to be achieved, its cost would be eternal vigilance.

As we have all become aware, public health judgements are exercised in conditions of uncertainty, even after all the expert parameters are taken into account. My gut feeling is that elimination is not achievable in current conditions in Australia, and even as reported new cases sink to zero, patches of undetected transmission will still occur, waiting for the right conditions in which to bloom into a renewed spread.

Seasons look likely to play a part. A Harvard team’s modelling of the post-pandemic spread of Covid-19 draws attention to seasonal dynamics that could affect transmission. Not only do they conclude that social distancing measures will be needed until 2022, they also suggest that recurrent wintertime outbreaks will continue to occur, with the greatest severity when outbreaks are established in autumn/winter. That possibility will no doubt propel Australian authorities to an even more cautious approach as winter approaches the southern states.

Meanwhile, the United States has proposed a robust set of criteria to be applied before phased “comeback” can take place. As well as reductions in symptoms and cases over a fourteen-day period and the capacity to treat all patients routinely, it includes a measure to determine “downward trajectory of positive tests as a percent of total tests within a fourteen-day period (flat or increasing volume of tests).” This metric cleverly gets around the incentive to reduce case detection as a means of decreasing the apparent size of the epidemic.

However robust, these criteria may be moot if civil disobedience becomes the main modality of epidemic coping. What may emerge instead is a de facto natural experiment. It will provide rich material for retrospective analysis but no comfort at all to those whose loved ones are lost.

Civil disobedience goes hand in hand with the negative spiral of blame shifting, which means that phylogenetics might be taking over from epidemic modelling as the next fad in armchair science. You can pick Nextstrain.org or choose Cambridge, with very different conclusions. While phylogenetics provides interesting insights into disease origins, it isn’t much use in responding to a pandemic as it is unfolding.

We know that perfect hindsight is no superpower in an epidemic. The first AIDS bestseller, Randy Shilts’s 1986 book, And the Band Played On, included a breathless account of Gaëtan Dugas, labelled as AIDS’s “patient zero.” Shilts garnered plaudits for his robust account of US government indifference and infighting, but even at the time his search for patient zero was questioned. That part of the book holds up even less well now that we know that the origins located at the time were way off track and provided no help in ramping up the AIDS response in the United States and globally.

Much more pertinent is close attention to the spread’s shifting dynamics alongside likely types of treatment. Here, one of the past week’s more interesting papers on the clinical management of Covid-19 suggested that a “disease tolerance” perspective was needed: “Instead of asking ‘how do we fight infections?’ we might start asking ‘how do we survive infections?’” Rather than targeting the pathogen, this perspective changes to ways of limiting damage to the host.

As Susan Sontag cautioned, rendering diseases in terms of metaphor is always dubious. But bearing this caution in mind, it is not far-fetched to say that our focus really needs to be on how we survive this pandemic in the weeks ahead, rather than on rehashing the steps that led us to where we are now.

“If we only knew then what we know now” is a forlorn cry. Back in 2001, if the world had known how much of the AIDS epidemic was still to come, there would have been no hesitation in adopting Jeffrey Sachs’s resource-unconstrained response. Let’s not make the same mistake today. •

The post Getting to zero appeared first on Inside Story.

As a health educator, I learned early on that different people have enormously different capacities to tolerate uncertainty. Some greet it with fatalism, shrugging their shoulders and continuing their daily routine. Others grip their keyboards with white knuckles, consuming every bit of news and trying to make it all fit together. As people in that second group find gaps or contradictions, they convince themselves that someone is either lying or incompetent. From this, we get the vocal insistence — despite all evidence to the contrary — that Australia has a secret policy of “let it rip” that would tolerate 3 to 5 per cent fatality rates to build up herd immunity.

The core of this mindset is the belief that someone, somewhere, knows everything and can control everything. Yet we live in complex systems in which nobody ever has complete knowledge or full control, and unexpected outcomes can emerge from behaviours enacted with quite different goals. In my own research, I use complex systems theory and methods to visualise and understand different social forms, including personal networks, organisations, cultures, communities, markets and policy spaces. One finding is constant: complexity teaches us we need to get used to uncertainty.

Right now, though, we are hearing from economists and think tanks and opinion writers and even medical journal editors, arguing that we must choose between two strategies, stick to just one option or focus on only one variable, or claiming that expert discipline X lacks a perspective only available to discipline Y or that experts can’t resolve it and simple models are all we need. At the end of March, for instance, the Medical Journal of Australia published a very simple model, based on Italian data, that predicted exponential growth in demand for intensive care beds in Australia. An accompanying editorial said that under conditions of complexity and uncertainty (anything involving human behaviour) “simple models may be more robust; at least early on, when they matter most.” And yet, in the fortnight that followed, the epidemic curve slackened and bent, invalidating that “robust” model. As H.L. Mencken observed, for every complex problem there is an answer that is clear, simple and wrong.

As epidemiologist Kathryn Snow has explained in the Guardian, more sophisticated models use data from observations of the real world to construct simulations within which we can experiment with different policy measures. The simulation isn’t a complete representation, of course. An attempt to model society in its full complexity would run into two insuperable problems: it would take too long to collect comprehensive data, making any answers out-of-date; and even if we had all that data, including so many variables would generate so many possible combinations that the simulation could not be computed at all.

In the aftermath of the global financial crisis, ecological scientists were brought in to survey the wreckage of the mainstream economic models that failed to predict the crisis even as it unfolded. Even in financial markets, where we do possess complete and timely knowledge of holdings, transactions and prices, these appraisals suggested that even with the most innovative models we can only make reliable predictions over a time horizon of a day or two, at most.

And yet we make plans for the future. We pass a budget, we make legislation, we plan a strategy involving a suite of measures in response to the local offshoot of the Covid-19 pandemic. If we can’t predict what will happen, and when, then how can we do any of that?

Coping with uncertainty involves taking action as a way of knowing. We make decisions based on all the insights available to us — not just models, surveillance data and peer-reviewed publications, but also things like professional experience, comparisons with other settings and anomalies observed in practice. The action we take and the effects we observe help us to better understand the system we are engaging with.

As a complex system, nothing about an epidemic is required to seem logical. The bulk of it is unseen: a virus moves through cells in organs in bodies and via encounters and relationships in networks and communities in populations. Minor coincidences can cause explosive, unpredictable outcomes — a food service worker, highly infectious but not yet feeling unwell, infects three dozen guests at a single cocktail party. Similarly, the diversity of people in a social network can determine whether an infection stays localised or travels across communities, countries and even continents. All of these factors can interact and drive significant changes in an epidemic without giving any advanced warning.

This requires us to be responsive — to pay close attention to all the different sources of knowledge available to us, and to be open to improvisation and adaptation. When members of the community and the commentariat understand this, they can see why we might shift from one strategy to another, and they do better at applying general recommendations to their own circumstances. This makes communicating the rationale absolutely vital. The demand for certainty is a barrier to a responsive strategy for epidemic control.

This is why it’s so encouraging to see deputy chief medical officer Paul Kelly talking about the endgame while the premiers are cautioning against expecting a return to normal life anytime soon, and the NSW chief health officer Kerry Chant talking about a “zigzag” approach to lifting restrictions while the modelling experts warn that easing up too soon might provoke “explosive resurgence.” As Harvard epidemiologist Mark Lipsitch says, “I think there’s going to be a lot of experimentation, not on purpose, but because of politics and local situations.”

These are not inconsistencies to be seized on or mutually exclusive positions to be debated in abstract terms. We can’t answer when restrictions might be lifted, but our governments are beginning to communicate how that might happen and what we might all need to be ready for, recognising that the pandemic, and our epidemic, will continue to evolve. •

The post Living with the great uncertainty appeared first on Inside Story.

But the escalation of Trump’s attacks on the WHO — directly proportional to the intensifying scrutiny of his own inept response to Covid-19 — makes it hard to avoid the topic, especially as Australia might find it challenging to distance itself from the American president’s stance.

Of course, I am not a disinterested observer. I worked for sixteen years for the multilateral organisation UNAIDS, whose dozen co-sponsors within the UN system include the WHO. The UNAIDS office in Geneva shared a building with staff from WHO headquarters across the road. Before joining UNAIDS I advised the WHO on a couple of projects. And I have many friends and colleagues who work for the WHO.

Regardless of my background, though, I think a strong case can be made against the two central allegations: that the WHO is too pro-China and that it was slow to call the pandemic.

The WHO’s earliest responses to the news of a novel coronavirus outbreak in Wuhan were careful to praise the Chinese authorities for their handling of the outbreak. The strategic reasons are simple: if an epidemic of potentially global significance is breaking out, you want the cooperation of the country in which it has emerged. In this case, there was also strong evidence that the Chinese authorities had learnt from SARS and were keen to support global transparency and sharing of information .

Critics point to Taiwan’s exclusion from the WHO at a time when that country’s response to Covid-19 is apparently among the world’s more successful. The WHO wants to pretend Taiwan doesn’t exist, say its critics, and is thus depriving the rest of the world of vital information about effective responses. In reality, the WHO’s position simply reflects the international diplomatic settlement known as the One China policy, which emerged in the early 1970s.

Ever since the UN vote in October 1971 that switched China’s seat at the United Nations from the Republic of China (Taiwan) to the People’s Republic of China, it has been the government in Beijing that has represented China in all UN bodies, not just the WHO, with the acquiescence of all the major powers. That hasn’t stopped Taiwanese journalists using the current crisis to try to trap WHO representatives into publicly conceding Taiwan’s status independent of China.

In reality, the WHO finds ways of working with Taiwan by keeping exchanges of information at the technical level. A global pandemic is not the time to push a reversal of the One China policy, and the irony of the recent debate is that it has made routine technical communication more difficult.

The WHO’s advice on the closing or reopening of “wet markets” has also been adduced as evidence of its pro-China bias. The term itself and its application exclusively to Asia indicates a desire to locate new disease threats in exotic, foreign and bizarre locations. Lurid pictures of snakes being cut up on chopping blocks and mysterious pots of meats darkly stirred are grist to this mill. The Australian politicians who say they are flabbergasted at calls to reopen “wet markets” don’t appear to be outraged by trading continuing at the Sydney Fish Market or Melbourne’s Queen Victoria Market. Unsurprisingly, the WHO has called for produce markets that are the main source of food to be open, with close and careful regulation of markets at which any live animals are sold.

The second charge against the WHO, also wrapped up with attacks on China, is that it acted too slowly. While conspiracists refer to intelligence reports of disease outbreaks in Wuhan as early as November 2019, the verified record suggests that a cluster of viral pneumonia of unknown cause was identified in Wuhan on 21 December 2019, and that Chinese authorities conveyed information about the outbreak to the WHO China office on 31 December. That information was then published on the WHO website on 5 January 2020.

To enforce international cooperation in the face of an epidemic, the WHO uses the International Health Regulations, which allow it to declare a Public Health Emergency of International Concern, or PHEIC. The process of declaring a PHEIC was examined in minute detail by the WHO after the experience of the 2009 H1N1 flu pandemic, when many critics felt the WHO overstepped the mark and caused global alarm about a threat that turned out to be no more serious than a seasonal flu epidemic.

The WHO was therefore determined to marshal unimpeachable evidence in its handling of Covid-19. Its emergency committee met on 22 January to determine whether the outbreak met PHEIC criteria. After a day of deliberation the committee could not agree that it did, and convened for a second day to reconsider. Again, it advised that the criteria were not met, and suggested reconvening in ten days. That proved too long a wait, however, and WHO director-general Tedros Adhanom called the committee together again on 30 January, at which time a PHEIC was declared.

Many were calling for the WHO to describe Covid-19 as a pandemic, which it did on 11 March. But it should be noted that a pandemic declaration has no particular force in international law: “pandemic” is neither defined nor used in the International Health Regulations. The WHO issued a considerable number of pandemic influenza guidances in the context of its response to the 2009 H1N1 outbreak, and these are often taken to be the WHO’s pandemic rules, but their status is no more or less weighty than any other body of WHO technical guidance.

Because of the alarm it causes, the WHO doesn’t use the word pandemic lightly. Its use on 11 March was designed precisely to elevate the level of alarm.

The WHO has also been criticised for a reluctance to urge travel restrictions in response to the Covid-19 outbreak. This too has a long history of controversy, with opinion divided on the efficacy of closing international borders in the face of epidemic outbreaks. In declaring Covid-19 a PHEIC on 30 January, the WHO noted that its emergency committee “does not recommend any travel or trade restriction based on the current information available” but that countries have an obligation under the International Health Regulations to inform the WHO about any travel measures taken, and the public health rationale for them. At the same time, the WHO urged countries to “place particular emphasis on reducing human infection, prevention of secondary transmission and international spread.”

North Korea became the first country to close its borders, on 22 January 2020. Singapore and Vietnam closed down flights to Wuhan and, from 1 February, many countries started ratcheting up their travel advisories and, progressively, their travel restrictions.

The WHO’s reluctance to call for international travel restrictions is longstanding, and in apparent contradiction to its advocacy of social distancing including in the Covid-19 case. Part of the explanation lies in the view that closing borders is a mark of xenophobia rather than epidemic control, and part in the fact that border closures are almost always too late and can breed complacency. As the modelling studies of Covid-19 have shown, only a few “seeds” need to find their way through restrictions for an outbreak to occur.

The view that border closures are often too late is borne out by phylogenetic studies of SARS-CoV-2, which use mutations in the genome to tease out the history of a particular instance of the virus. Here, Nextstrain has proved to be one of the more useful tools developed during this pandemic. Building on thousands of virus genome samples deposited with an international registry, it has traced cases from the outset and mapped the spread. If you want to ponder the potential impact of border closures, pick your preferred date and adjust the time frame accordingly — it will show you how far the spread had already gone.

When Ebola broke out in 2013 in West Africa, the WHO was widely criticised for the inadequacy of its response. It was hamstrung by the unwieldy structure of politically appointed regional directors and country representatives overly subject to the national sensitivities of the countries in which they were based; headquarters was still smarting from criticism of its handling of the 2009 H1N1 pandemic; and the international community was barely raising a finger to support the countries affected. It was only when health personnel from wealthy countries began to be repatriated with Ebola that any attention was paid.

One argument made when Tedros was running for election as the WHO’s director-general was that his country of birth and experience as a foreign minister would help him cut through some of these political issues. And, indeed, one of Tedros’s major early successes was the Ebola response.

All this means that it is deeply unhelpful to try to adjudicate on the quality of the WHO’s response while this epidemic is still gathering steam. The judgements will come later, and my feeling is that they will be positive.

Even as Trump was suspending WHO funding pending review, the crisis in his own country’s testing capacity was pushing the story into the background. No one should wish any more suffering on the American people. Case numbers there will soon approach the million mark, notwithstanding the test shortfalls. With no evidence that fatality rates are lower in the United States than elsewhere — if anything the opposite — the number of deaths will inevitably pass the 100,000 mark. Care, treatment and vaccines are desperately needed.

This is the real issue. Forget the rest. •

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Like many who returned from the war, she never talked much about her experiences — just an occasional remark, mostly about lighter moments, never about the terrible ones. What stuck in her mind about El Alamein, I recall her saying, was how loud the sound of the artillery had been through the night, and how long it lasted. She would never hear a word spoken against the Salvation Army, who were as close as possible to the front line offering cups of tea and comfort.

The second battle of El Alamein — exactly halfway through the six years of war, as it happens — was pivotal. The Allies never won a battle before it, Winston Churchill wrote, and never lost one after. It was the prompt for the British PM’s famous November 1942 speech, which included the lines “This is not the end. It is not even the beginning of the end. But it is, perhaps, the end of the beginning.”

New York’s governor, Andrew Cuomo, quoted those words last week as the rate of the rise in deaths from Covid-19 started to decline in his state. But I am not sure we have yet fully grasped what they really mean when they’re applied to these figures. The risk is that the “curve” starts heading down and wishful thinkers start declaring victory. As Churchill also said in that famous speech, “I have never promised anything but blood, tears, toil and sweat,” and there is a lot more of that to come before we see off Covid-19.

Perhaps the clearest picture yet of what it will take to control the rebound after the first wave of infection subsides comes in a paper published by the Lancet this week. Kathy Leung and colleagues from the University of Hong Kong look in detail at provinces outside Hubei in mainland China. As others have done, they point to the importance of keeping the reproduction rate below one (R_t<1 in their terminology), but they also highlight that any return to a rate above one would ratchet up the baseline number of infections in the community. This means that “simply tightening control interventions again to maintain R_t=1 would not reduce the burden back to its original baseline”; to do that would involve extra effort:

Therefore, relaxation of interventions to allow R_t>1 would probably incur both marginally higher health and economic loss, even if the disease prevalence could subsequently be pushed back to pre-relaxation level. Thus, proactively striking a balance between resuming economic activities and keeping R_t below 1 is likely to be the optimal strategy until effective vaccines become widely available.

Singapore is perhaps the clearest signal for Australia. It established the gold standard for successful initial responses to the virus but has now gone into a more aggressive “circuit-breaker” period of lockdown, including school closures, in response to new local clusters of infection, even as cases coming from overseas have reduced to zero. The first of the resurgent cases were found in foreign-worker dormitories, but here also Singapore has established a gold standard, with prime minister Lee Hsien Loong’s promise to pay “close attention to the welfare of the foreign workers.”

On Friday, Lee reminded Singaporeans that these workers “came to Singapore to work hard for a living, and provide for their families back home.” They have played an important part building Singapore’s high-rise flats, Changi Airport, and mass-transit lines, he said. “We have worked with their employers to make sure they will be paid their salaries, and can remit money home. We will provide them with the medical care and treatment that they need.”

Kathy Leung and her colleagues propose that one way of maintaining the vigilance needed to manage rebound would be to develop “digital proxies for social mixing and human mobility” using the ubiquitous smartphone data collected on apps like WeChat and Alipay (no one in China uses cash any more). To assess your likelihood of harbouring the virus, they would build on the system already developed to regulate public movement in China during the epidemic according to the green, yellow or red code your phone produces.

But before you say “that’d only work in authoritarian societies like China” consider this: Apple and Google are collaborating on uses of bluetooth low-energy transmission data (the signals exchanged between phones in near proximity) to enable Covid-19 contact tracing; and Facebook’s Data for Good initiative has developed co-location maps to reveal the probability that people in one area will come in contact with people in another, as well as “movement range trends” showing whether people are staying near home or visiting many parts of town.

The alternative to big data surveillance in epidemic control is grassroots, movement-based organising, which can develop local solidarity and manage prevention and transmission as well as response. To date, other than symbolic gestures of applause or sharing of cute memes, there has been little sign of systematic movement-building. When central authorities spend much of their messaging capital on reinforcing heavy-handed policing, they undermine the notion that communities working together can find appropriate solutions. Perhaps now is the time to flick the switch to solidarity.

The lasting alternative to these non-pharmaceutical interventions will only come from an effective vaccine. The good news is that, as of 8 April, 115 candidate vaccines against SARS-CoV-2 were in the works. The bad news is that a survey of the vaccine field from 1998 to 2009 showed that even once candidate vaccines get to the pre-clinical development phase they take an average of nearly eleven years to reach market, and only 6 per cent make it through the journey. Can things be different this time? The head of the Gavi vaccine alliance, Seth Berkley, has called for a “Manhattan project” to develop a SARS-CoV-2 vaccine, involving “extraordinary sharing of information and resources.” A race to see which vaccine candidates perform best is fine for the initial stages, but then a process is needed to pick the best and take it to scale.

Warnings have already been made about fairness. Unlike the 2009 H1N1 flu pandemic, when “rich countries negotiated large advance orders for the vaccine, crowding out poor countries,” governments will need to establish a globally equitable allocation system.

This is perhaps the biggest challenge. In his Easter Sunday Urbi et Orbi message, Pope Francis firmly sided with global solidarity and against self-centredness. He may have had in his sights the US president, who exemplified all that is wrong in a competitive race to protection with his boast that he had talked with “genius” pharmaceutical companies to rush the latest experimental treatments to Boris Johnson in intensive care. The offer was politely refused, and when the British prime minister emerged from hospital he thanked the National Health Service for saving his life. There could hardly be a starker contrast between billionaire boasts of special access and an endorsement of a health service that holds equitable access at the centre of its values, even (or especially) when it is under tremendous strain.

One of the most convincing voices to have emerged in recent weeks on the theme of global solidarity is Spain’s newly minted foreign minister, Arancha González Laya. Commenting on Europe’s north–south split over mutual financial support, she singled out the trenchant Dutch opposition to assisting countries like hers. “We are all in the same European boat” that has run into an iceberg, she said, and all of us are facing the same risks, whether or not we are in first-class berths.

Famously, survival rates from the Titanic demonstrate that first-class passengers did indeed have a better chance of making it out alive (although gender and age had an even larger impact — it was a case of “women and children first”). Those whose chances were the poorest were the crew — perhaps most analogous to the doctors, nurses, cleaners and orderlies staffing health facilities on the front line of this pandemic.

It has often been said that AIDS was an “equal opportunity disease.” Like Covid-19, wealth and education have been no barrier to infection. In that sense we are all in the same boat. But once the boat is sinking, your chances are indeed strongly affected by class, hence the spectre in the United States of much higher Covid-19 death rates among African-American populations.

These inequities won’t fix themselves, but they can be fixed, and we ought to take heart from the chorus around the world demanding it.

Perhaps the neoliberal era will end with both a crash and a whimper. •

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A librarian and historian, Matt was the family history sleuth for my recent collection of memoir essays, and his grasp of our family’s story is much more detailed than mine. I was aware that my mother’s young sister had died as a child but not that she had been struck down at the age of three by the devastating flu that killed at least twenty-five million people, and possibly as many as one hundred million, just after the first world war. My middle name is Joyce, after the aunt I never knew.

Going back through the transcripts of the tapes Matt recorded with his grandmother in the 1990s, I found a comment she had made about her childhood in Watford, near London: “After the war we had a terrible flu epidemic and we all got it, but with Joycey it turned to pneumonia and she never really recovered from it.” The delicate little girl started school but had to give up through illness; she was then nursed at home by her mother until she succumbed to heart failure in 1924, just after her eighth birthday.

The influence of chance on the trajectory of our lives has always fascinated me — how planned paths swerve as a result of an unexpected personal event, or how wars, or indeed pandemics, turn those plans upside down. Thirteen when her sister died, my mother was attending a secondary school that provided early teacher training and was planning to complete the qualification at a college in London. She knew the direction her life was to take. Or so she thought. In fact, having immersed myself in our family archive, delved into Trove and consulted with Matt, I have come to see that the effects of my young aunt’s death from Spanish flu rippled so widely that my very existence can be traced back to it.

My mother, Rose Wythe, lived with her parents and little sister in a comfortable rented house in Watford, its front covered in a Virginia creeper that became “just one big splash of red” in autumn. My grandfather ferried around travellers by horse and trap as a coachman for Kinghams, a large grocery store that smoked its own bacon and hams. My grandmother was the homemaker. My mother loved her school life and the company of her girlfriends there. She was a born teacher, and I feel sure she would have helped Joycey with lessons when her sister was well enough. (She taught me to read at three before being called back to teaching after the second world war.)

Joyce Wythe was buried at Watford cemetery on 23 June 1924, and her grave is watched over by a stone child angel. After the funeral, the house with the Virginia creeper fell silent. Like her father, my mother continued to come home for lunch, but “sometimes there was lunch ready and sometimes there wasn’t. It was a very sad time.”

My mother’s two older brothers had found it hard to enter the workforce after the war ended in 1918. “Lewis was apprenticed to engineering and after the war the soldiers who did come home got their old jobs back,” my mother told Matt. “So that was the end of his apprenticeship. And it was very hard to get anything else. Wilfred was younger — he was very clever artistically and he really wanted to be an architect, but that was wiped on the head too.”

Seeking more opportunities, the two young men had set off to Australia in the first wave of postwar emigration. After Joycey died, Lewis implored his parents to join him and Wilfred and, in their unhappy state, my grandparents eventually agreed to set sail for the other side of the world. My grandmother seems to have regretted the decision for the rest of her life; and my mother, of course, was devastated. “I suppose these days,” she told Matt, “I would have stood out and said I was going to stay behind, even if I got a job to help me. But you did what your parents said then.” At fifteen, she really had no choice.

Before the family set sail in early 1926, my mother spent as much time as she could with her friends, staying the last night at the home of her best friend, Doris. She made sure that two small autograph books I hold in my hands today were packed in her trunk as precious mementos of the life she was to leave behind. They consist mostly of sentimental verses about friendship or extracts from poems by Tennyson, Kipling and others, all written in carefully formed cursive script and signed by friends or teachers.

Interspersed are pen and ink drawings and watercolours, including drawings by one of my mother’s cousins, a teenage boy at the time, from Aldeburgh in Suffolk. Dated August 1921, they show that he was fascinated by the machines of war — airships, warplanes and steamships — that he had grown up with. Watercolours of flowers by my mother’s friend Doris stand out for their artistry. The two women were still corresponding seventy years later.

A farewell watercolour by Rose’s friend Doris.

The voyage on the P&O steamer SS Barrabool, bound for Adelaide, Melbourne and Sydney with more than 1000 emigrants on board, was more eventful than any of the passengers could have imagined. My grandmother, a “bad traveller,” was seasick for most of the journey and confined to her cabin. So she wasn’t among the passengers who stood on deck for hours — in the middle of the Atlantic Ocean, en route to Cape Town — watching a lifeboat ferrying people from a burning cargo ship, the Parapoa, which carried sixty-nine crew and five passengers. All were rescued safely, including six stowaways and a pedigreed fox terrier. An open crate of pigeons remained on the ship, left to fly away if they could. Those rescued were disembarked at Cape Town, and that was where, according to my mother’s memory, passengers with smallpox were unwittingly taken on board. Five people would die over the next weeks.

Newspaper accounts of the outbreak on the Barrabool vary, but the one in the Adelaide Advertiser of 12 April 1926, which describes the scene after the ship docked at Semaphore, resonates uncannily with accounts of Covid-19 on cruise ships docking in Australian waters in 2020:

The vessel was boarded by Drs. C. Wiburd and P.T.S. Cherry, who were handed the primary health report, which stated that no sickness had occurred on board, with the exception of a series of cases of measles among children. However, as Dr. Wiburd was leaving the ship’s hospital, he noticed two male passengers on the deck with a rash on their faces which indicated smallpox. One of the men seemed to have had only a mild attack of the disease. Both sufferers, who had been in a febrile condition, were mingling among other passengers on the deck… Drs. Cherry and Wiburd, in the course of the examination of the other passengers, found another man whose face, hands and feet were covered with the scars of smallpox. He had taken ill shortly after the vessel had sailed from Las Palmas, and after being detained in the ship’s hospital for some days, was discharged.

The passengers bound for Adelaide and those who were ill were taken to the quarantine station on Torrens Island, where they were disinfected, vaccinated and placed in quarantine. The remaining passengers heading to Melbourne and Sydney were vaccinated on board before the ship resumed its delayed journey. From Port Melbourne approximately 300 were taken to the Port Nepean Quarantine Station, perched on the rugged coastline at the tip of the Mornington Peninsula. Some 600 passengers then continued on to Sydney.

The Melbourne Argus announces the Barrabool’s quarantine.

Those sixteen days’ quarantine at Portsea were my family’s introduction to their new country. My mother remembered the seaside town as a beautiful place, although the station itself was very plain and the inmates slept in barracks. She would have seen the administration building, erected in 1916, with its handsome facade, but that is not where the internees were housed. In her recollection, “ships came back, I don’t know how many times, bringing the dead — the Sydney people. It was an awful beginning.”

Although that part of her story can’t be verified, an account in the Melbourne Age of 30 April 1926, two days after most of those quarantined were released, does support some of her memories:

The first case of small-pox was recorded at Las Palmas, and during the continuation of the voyage a number of the vessel’s passengers contracted the disease. During the latter part of the voyage five deaths were recorded. Two of the crew and one passenger contracted pneumonia with fatal consequences. A girl of thirteen years also died of the malady. The last death was recorded on Monday, when a child two days old died.

The quarantine station at Portsea had opened in 1852, making it one of the first in Australia. The oldest buildings on the site, which continued operating until 1980, date back to that period. It was the scene of part of the little-known history of Spanish flu in Australia, after servicemen suffering from the disease started pouring back into the country from the war in Europe in 1919. Twelve emergency timber huts were hastily erected, each holding thirty-two men, which suggests the victims numbered in their hundreds. In total, an estimated thirteen to fifteen thousand people died in Australia during the pandemic.

Because my grandfather reacted badly to the vaccination and had a severely swollen arm, my family was kept at Portsea for a week longer than most of the new settlers. As my mother recalled, “I had a pretty bad arm, but my father’s was terrible… And Mother, who had been so sick on the ship, was immune to the vaccination — it didn’t have any side-effects at all.” With Wilfred having already moved to Sydney, the travellers eventually met up with Lewis in Melbourne. Instead of finding accommodation for them in the city, he took them twenty miles away to Werribee, then a small country town. There, my grandfather found work as a stableman and labourer at the State Research Farm, where he would spend the rest of his working years.

My grandmother hated Werribee and my mother resented Lewis for the rest of her life. “He was always doing the wrong thing, that brother,” she told Matt. “I don’t owe him anything. He was such a queer bird. Funny how people can be so different in a family.” It seems that the feeling was mutual; as she remarked dryly to Matt, “He was the one who told me that if I ever knitted anything for him he wouldn’t wear it anyway. So I didn’t knit anything for him.”

In spite of these inauspicious beginnings, Werribee was to play an important role in our family history. My mother became a relief teacher a few years after she arrived, leaving the little town for extended periods to work at single-teacher schools around the state. But Werribee was where she met her future husband, who was working in his father’s cafe and playing piano in a local band. They married in Scots Church in Melbourne in 1935 and, using my father’s skills as a pastry chef, opened a cake shop in the eastern suburb of Glen Iris.

Their suburban life was short-lived. When the second world war broke out in 1939 — the second world conflict they were to live through — my father joined the airforce and my mother followed him from posting to posting with their baby son. I arrived towards the end of the war and, after my mother was recalled to teaching during the early postwar boom, I started school before I turned five.

In the light of my family research, I pondered again the question of why the Spanish flu has left such a small footprint on our collective memory and came up with some possible answers. The pandemic came on the heels of a war that ravaged the world, of course, and has thus remained hidden in its shadow. More than that, my parents’ generation lived through a century that encompassed not one but two world wars. As well as causing death and disaster, wars can create the heroes and narratives that define a nation; pandemics offer no enemy but the disease itself, and are thus harder to memorialise. People simply wish to forget them.

In a collection of essays on the history of quarantine, Anne Clarke, Ursula K. Frederick and Peter Hobbins remark on the inconsistency between historical records and stone inscriptions. They speculate that the paucity of inscriptions mentioning disease at quarantine station sites could reflect “a strategic amnesia — a way of moving forward and beyond the spectre of death.” Mentioning the SS Barrabool as an exception, they observe that the vessel is virtually missing from the historical archive (and the varying accounts I did unearth are wildly inconsistent) and yet its smallpox cases are mentioned on a number of rock inscriptions around the quarantine station at Sydney’s North Head, which was the ship’s final destination on that fateful voyage. Perhaps the discrepancy can be explained by the fact that forty of the passengers on board were stonemasons who were specially recruited in England to craft the stone foundations of the Sydney Harbour Bridge.

Uncovering small stories like my family’s can shed light on the larger narratives of wars and pandemics. Writing this, in the midst of the coronavirus, a century after my young aunt was stricken by the Spanish flu, I find a certain ironic symmetry in our stories. Joycey was a child during a pandemic that struck children in larger numbers than any other age group. This time it is the older generation that is most vulnerable and I am completely housebound, except for a daily walk with the dog, for the foreseeable future. I am one of the privileged, though, as I share my comfortable home with my partner, with my books, archives and the internet at my fingertips, and with frequent virtual access to family and friends. •

My thanks to Matthew Stephens for his assistance in the research for this essay.

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This week, the US Centers for Disease Control and Prevention joined in, endorsing the use of masks by the general public. A flurry of articles have struggled to filter the evidence for and against. Some commentators are even saying the evidence now shows that SARS-CoV-2 is capable of not just droplet transmission but airborne transmission too. So, what can we make of all this? Here are three key things you need to know before you pull on that mask.

HOW COVID-19 IS TRANSMITTED

The virus that causes Covid-19 is known as SARS-CoV-2. Initially of animal origin, it aroused global health concern when reports of human-to-human transmission emerged in December 2019. After it began spreading in Wuhan, the city was locked down and 1800 teams of five or more epidemiologists descended, tracing all cases and their contacts. That research provided a detailed picture of what happens before control measures are put in place, and it found that the average person who contracted Covid-19 transmitted the virus to 2.2 other people over the duration of their illness. Importantly, they were almost always people with whom they had close and prolonged contact.

Some people have interpreted the recommendation that we keep at least 1.5 metres from each other as meaning the virus is easily passed on via brief and casual contact. The contact tracing carried out in Wuhan gives a better picture of how this condition really is transmitted.

When we say a viral pathogen is capable of airborne transmission, we mean two things at once. One is that people who are sick cough up particles of five microns or less, which are typically generated deep in the lungs and can hang in the air for hours after a cough or sneeze. The other is that inhaling those particles is enough to cause a new infection.

You can catch measles, for example, by walking into a room that somebody with measles coughed in hours earlier — you don’t need to have direct contact with that person. This is why measles spreads like wildfire in unvaccinated populations, as we saw recently in the tragic outbreak in Samoa.

The spread of SARS-CoV-2 beyond its epicentre in Hubei coincided with Chinese New Year, when people from all over China travel for hours at close quarters on planes and trains back to their home towns. If Covid-19 were airborne, that would have been clearly visible in the epidemiology of the outbreak.

Epidemiologists in China were almost always able to identify whom each person had caught Covid-19 from, because the two people had spent time in close physical proximity, where droplets from coughs and sneezes can be transferred from surfaces, via hands, onto faces.

If the condition were airborne, there would have been many cases of transmission — of genetically linked virus — where the people involved were never in the same room at the same time. With upwards of 80,000 cases in China, we have a high degree of confidence that Covid-19, rather than being airborne, is passed on via droplet transmission.

Some mask proponents cite a study that found SARS-CoV-2 particles in “air-conditioning ducts” as evidence of airborne transmission. The ducts in question turned out to be the extractor vent for a negative pressure isolation room occupied by a symptomatic patient at an outbreak centre in Singapore. The same study used sensitive methods to test for virus in the air itself — and all of those tests came back negative.

Mask advocates also cite a recently published study that found genetic material from viruses that cause influenza and head colds in exhaled breath. Other studies have reported droplets from sneezes travelling up to eight metres from the sneeze that produced them.

These studies don’t answer a key question: were there enough droplets after eight metres; did they have enough virus in them; and was the virus infectious enough to infect another person in the absence of close and sustained contact?

The answer depends on the illness and even varies according to the strain of the virus within broader viral families. In this outbreak, we have no evidence to believe that SARS-CoV-2 is capable of airborne transmission.

Rather, Covid-19 is passed on when coughs and sneezes spray droplets of mucus and spittle onto nearby surfaces. When we touch those surfaces, we may transfer them to our face, allowing the virus to establish infection. This is why we recommend handwashing, avoiding facial touching, coughing or sneezing into your elbow, and keeping a physical separation from others.

WHAT (AND WHO) MASKS ARE GOOD FOR

Mask advocates are correct in picking up an apparent contradiction: why are masks protective for healthcare workers but not for the general public?

It comes down to social distancing. Doctors and nurses can’t listen to your chest from 1.5 metres away — they have to get right up in your grill, within the blast radius for coughs and sneezes. Guidelines in Australia recommend a surgical mask for face-to-face treatment of patients with confirmed or suspected Covid-19 illness. There’s an additional subset of treatments, known as aerosol-generating procedures, which call for an N95 respirator. This includes lifesaving interventions like intubation. So it’s vital we preserve clinical wear for clinical care.

Clinicians get no benefit from using higher-grade personal protective equipment, or PPE, than recommended. Anyone who is unfamiliar with this equipment runs the risk of accidental self-contamination when taking it off, as we saw during the Ebola crisis.

Surgical masks are also given to clinic and hospital patients who have respiratory symptoms, or who are confirmed or suspected cases of Covid-19. This is known as source control, with masks protecting others by catching droplets from coughs and sneezes. This is essential when people with symptoms seek out medical care. Other than that, if you have symptoms, or a recent close contact with a known or suspected case, you should not be out in public at all — mask or no mask, you should be at home in self-isolation.

If you’re not in either of those categories — a healthcare worker getting up close and clinical, or a person seeking testing or medical care — is there any benefit in using a mask? The potential benefit depends on how much risk you would be facing without the mask.

The Communicable Diseases Network Australia defines two conditions where the risk of Covid-19 transmission is greatest: close and sustained personal contact. Close contact means face-to-face for fifteen minutes or more; sustained contact means sharing a closed space for a prolonged period (two hours plus).

Brushing past someone in a supermarket aisle is unpleasant at a time when our anxiety levels are heightened, but it’s not a significant risk. The benefit is much greater for clinical workers who have close and sustained contact with known and suspected cases of Covid-19, so we should prioritise their access to clinical masks.

Some people want to wear masks when they can’t avoid getting close to others, for example if they are waiting in a long queue for Centrelink or have no choice but to catch public transport to work. Many of us are already going outside as little as we possibly can, and we want to do everything we can to protect ourselves and others when we do venture out.

That’s completely understandable. Keeping our physical distance from others whenever we can, keeping our hands clean, and minimising touching our faces and common surfaces remain the most effective things we can do to protect ourselves and other people when we’re out and about. To protect others, we should not be going out at all if we have any cold or flu-like symptoms, unless we are headed straight to the doctor’s office. And if wearing a face covering would make you feel safer, the next section offers you some options.

IF YOU REALLY WANT A FACE COVERING

We have already begun to see people on Twitter seeking to shame or stigmatise anyone who goes out in public without wearing a mask. This is a concerning development. Stigma is a powerful regulatory force — anyone can pick it up and use it to shape someone else’s behaviour. But once stigma is unleashed, once we reinforce social norms with blame and shame, it can’t be undone, even when it produces unintended consequences. We need to ensure that our use of face coverings does not put healthcare workers at risk of infection and death with Covid-19.

There is a major shortage of PPE, which includes the surgical masks and N95 respirators used by healthcare workers to treat patients without contracting the virus themselves. A petition with over 152,000 signatures calls for transparency about the Australian PPE stockpile, with some healthcare staff quitting over the lack of protective equipment.

In some countries up to 10 per cent of Covid-19 deaths have been healthcare workers. If you want to wear a mask, your first thought should be avoiding contributing to the dire situation facing doctors, nurses and paramedics — not least because they deserve our care, but also because you, or your loved ones, may still end up needing their help. None of us should be using medical masks that might be needed by health professionals who are trying to save our lives.

The first step is not to buy masks for yourself. You might think, “Oh, two or three won’t hurt,” but you’re creating a demand that will divert stocks from where they’re needed. We’ve just seen what happens when everybody buys “a little bit extra” pasta and toilet paper. If you already have a mask you bought during the bushfire crisis, go right ahead. You could also follow instructions to make your own face coverings, which were written for healthcare workers who can’t obtain the real thing. Studies have shown these coverings are less effective than manufactured masks for healthcare workers, but this may be offset by the much lower risk you are facing in everyday life.

Second, there’s important information embedded in those DIY instructions. They tell us to make plenty, as masks quickly become saturated with moisture from breathing and need to be replaced regularly. If you have Covid-19, a damp mask is full of viral particles ready for droplet transmission. Touching these contaminated masks and then touching surfaces is dangerous to other people. Used masks should be plastic bagged and go straight in a hot wash overnight.

Third, if you are wearing a mask to protect yourself, you must teach yourself not to adjust the mask with your fingers — that’s facial touching, and it will put you at risk. Droplet transfer is still the biggest risk for infection by far, and masks can increase that risk. Learn how to put facial coverings on and take them off so you don’t end up brushing their exterior surfaces with your fingers, or against your face — even healthcare workers find this a challenge. Always wash your hands before and afterwards, and don’t relax about physical separation.

Wearing a face covering can be a potent signal that you are doing your bit to curb the epidemic. But if we all begin buying and wearing clinical masks in public, that symbolic gesture will pose a very concrete risk to healthcare workers’ lives. Making your own face covering lets you signal your care about your own health, the safety of our doctors and nurses, and ending the outbreak. If you want to cover your face, this is a very personal, concrete and practical approach. And even the US surgeon-general is getting in on the act. •

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Libertarian think tanks and law and economics professors expressed concern that the cure might have been worse than the illness. (This, of course, is a position you can only hold if the cure actually works.)

From all quarters came calls for caution against complacency. Some commentators who had courted panic by interpreting the initial slope of the curve as evidence of exponential local transmission now scrambled to point out that the slowing reflects the drop-off in overseas visitors, with local transmissions continuing their trend of gradual increase. Advocates of an elimination strategy argued that now is the time for lockdown, scenting the prospect of completely eradicating local transmission.

As the pace of new diagnoses begins to slow, at least for the moment, it seems a good time to reflect on the mid-to-long term. What would an endgame look like?

We have had an intense debate over what broad approach we are taking — flattening or bending the curve, or complete eradication. In practice, the methods are the same; the difference is a matter of timing and emphasis. But debate still rages over a false dichotomy expressed in loaded terms: after all, who wants to advocate a policy widely described as mitigation?

Yet “flattening” includes preventing cases, not just spacing them out so that hospitals can cope, while “eradication” anticipates that the epidemic would rebound if restrictions were eased too early or lifted altogether.

Nobody at the centre of Australia’s response to the epidemic believes we are going to see results from a “short, sharp shutdown,” as advocated by some vocal commentators. At state and federal levels, chief health and medical advisers say restrictions must remain in place for months and may intensify.

In the discipline of change management, there’s a saying, attributed to Peter Drucker, that “culture eats strategy for breakfast.” Simple and decisive strategies like lockdown can easily founder on the shoals of implementation. The PM has fairly been criticised for making a hash of communicating the government’s piecemeal introduction of recommendations and restrictions. But that graduated introduction, with heavy foreshadowing of tighter restrictions to come, has given the public time to prepare, mentally and practically, for a curtailment of everyday life that is likely to be a marathon rather than a sprint.

The big question is what happens when restrictions are lifted: does the epidemic rebound? This is where notions of flattening or bending the curve fall short. The most well-known alternative is a model developed by Neil Ferguson and popularised by startup founder Tomas Pueyo that explicitly anticipates rebound. Pueyo called its two moves “the hammer” — an initial, immediate, short, sharp lockdown — and “the dance” — monitoring the epidemic and pulsing restrictions on and off, as needed, to curb the epidemic’s growth.

What this fantasy born of simulation overlooks is that policy involves people. Trying to plan ahead without any certainty about whether and when restrictions will be reimposed will become extremely burdensome. As the public tires of the dance, adherence will decrease, and it will lose effectiveness. Of course, this problem applies equally to all restrictions.

It all comes down to rebound. If Australia succeeds in bending the curve, does the rate of new infections simply return to unacceptable levels when restrictions are lifted?

We can easily imagine rebound happening if travel bans are lifted while the pandemic rages unchecked beyond our borders. Within our borders, though, Australia relies on precarious migrant labour — people whose lack of social security means they have to work in order to survive, even if they have mild respiratory symptoms. Low-level ongoing transmission among workers exempted from stay-home measures, be they permanent residents or otherwise, could allow rebound even without any easing of overseas travel bans.

We are watching carefully for rebound in countries that have controlled their initial outbreaks using the same approach as our own — intensive social distancing, aggressive contact tracing, and isolation of known and suspected cases. Both China and Singapore, exemplars of this approach, have reported mild increases in cases involving local transmission. Singapore this week opted to introduce more intensive social distancing measures involving shutdowns.

Epidemics are complex and unpredictable, and a cluster or super-spreader event could change the behaviour of our outbreak altogether.

We don’t know if or when a vaccine will become available. Until that happens, we are facing prolonged restrictions and ongoing uncertainty about the endgame. Our approach needs to respond to our own epidemic, our own population and our own health service capacities. It will not slot neatly into some conceptual debate, nor should we expect it ever would. •

BONUS READING

This article includes some text from a new resource by the author outlining the evidence and experience underlying Australia’s recommendations for preventing transmission and curbing the outbreak. It’s available free here.

The post Reflecting on the endgame appeared first on Inside Story.

For some, this closing of borders is a sign that globalisation was all a big mistake — that Covid-19 proves we should retreat into smaller and smaller communities. Others see travel restrictions merely as a pragmatic way of slowing viral spread, and point to flourishing global solidarity in shared experiences of quarantine.

The debate is an old one. Human geographer Yi-Fu Tuan is just one theorist who has pointed to divergent attractions of the hearth — with all it implies in terms of closed, monocultural societies — and the cosmopolitanism that must make rules to accommodate difference within shared social space.

Ilona Kickbusch, director of the global health program at the Graduate Institute in Geneva, has suggested that a “cosmopolitan moment” occurred when the experience of SARS cemented a global commitment to the International Health Regulations: “Cosmopolitan moments are points in time at which the global community comes together and creates new institutions and mechanisms that it has not otherwise been willing to introduce.” Covid-19, she writes, is just such a moment, teaching us “that international solidarity is an essential response and a superior approach to isolationism.”

Despite the recognition of Covid-19’s spread to nearly every territory on Earth, national differences in epidemic curves, infection rates and death rates have been eagerly seized on. Those comparisons have been used partly to calibrate the intensity of a country’s own responses, especially when it comes to restrictions of movement. Naturally, the success or otherwise of epidemic containment strategies and their associated models has been eagerly pored over. (Perhaps too eagerly in some cases — thirty-six hours after the head of the Imperial College modelling team, Neil Ferguson, attended 10 Downing Street in mid March he came down with the telltale Covid-19 symptoms and tested positive. He has since recovered.)

But some of the differences don’t yet have a good explanation. Why are Germany’s death rates a tenth of those in Italy, for example? Will the disparity be sustained? Are they real differences in clinical progress, or just a marker of different stages in the epidemic and different denominators of the size of the infected population? As the former Chinese premier Zhou Enlai might remark, “Too early to say.”

Chance cannot be discounted as the underlying reason for these differences. For nearly two decades, it was a mystery why HIV rates in the Philippines and Japan had remained so low, even in the most likely populations, such as gay men. All the risk factors looked similar to comparable countries in the region and across the world. Then, in the early 2000s, HIV rates suddenly took off in both countries, and the response that had been on hold for years had suddenly to be ramped up.

Epidemics are subject to the dynamics of population mixing patterns, environmental and other conditions, and purely chance infection events. Even subtle differences can have major impacts, so it is important not to over-interpret models or emerging empirical evidence.

It is even possible that the origin story of SARS-CoV-2 will change, and that ground zero may not be a wet market in Wuhan. There have been intriguing signs of clusters of unexplained severe pneumonias in northern Italy as far back as October 2019, and epidemiological detective work is being undertaken by the University of Milan’s Professor Adriano Decarli. Chinese media have amplified the theory that the virus originated in Italy and was transported to Wuhan — the vector in either direction being the trading links between the two regions, eerily reminiscent of the plague’s progress along the old Silk Road.

The Silk Road also features in a heated debate in international relations circles between those who welcome China’s post-Wuhan assistance to a world in need via a “health silk road,” and those who decry this as propagandising. As Chinese writer Wang Xiuying wryly reflected back in February from lockdown in Wuhan, “In the West, panda-huggers say no other government would be doing better [than China’s] under the circumstances; dragon-slayers are cheerleading for the end of communist rule, as they do every time there is trouble in China. Whatever happens, those arguments won’t change.”

The brute force of the epidemic will shape those debates, nowhere more so than in the United States, where the limitations of market-based healthcare are being laid bare. Healthcare interest groups, trained to maximise their profits, are behaving badly amid rampant profiteering and the hoarding of intellectual property. System infrastructure shows many signs of fracture.

Something clearly went wrong with the high-profile global health security index, released last year, which ranked the United States as the country best prepared for a pandemic, and Britain second. (Australia was in fourth place.)

Some countries, meanwhile, have surprised in the strength and quality of their response. Given South Africa’s tardy and conflicted response to HIV, which left it with the world’s biggest epidemic, it may have been expected to struggle with the added challenge of Covid-19. But perhaps the long challenge of HIV led to all the necessary learnings. In my view, South Africa’s Covid-19 health portal is the best in the world: the number of tests, positives, recoveries and deaths are displayed in a daily ticker, and links provide clear and coherent video guides for all audiences. President Cyril Ramaphosa has provided clear and calming leadership, initiating a three-week nationwide lockdown from 26 March. Health minister Dr Zweli Mkhize has run the day-to-day response, which includes mobile testing units.

That is not to say challenges won’t arise. Many South Africans have very few resources on hand to tide them over, even for the briefest periods. Over the border in Zimbabwe, which has been struggling with a comatose economy, the situation is worse. A few days ago I was forwarded a WhatsApp message from a single mother in one of the poorer suburbs of Harare who had been warned, and was able, to stock up on goods before the nationwide lockdown came into force: after three days, she said, her neighbours are crying out of hunger. When water comes from a communal pump, the practicality of physical distancing also comes into question.

It’s easy to become obsessed by the unfolding epidemiology of a pandemic. But the epidemiology is only one small part of a picture, and is mainly useful to predict what case numbers are coming down the track. The much bigger part of the picture is the response itself: the changing of behaviour to minimise cases and the treatment given to those who fall ill.

The US National Institutes of Health’s global database of clinical trials today lists 306 registered clinical trials for Covid-19 treatments. Some potential treatments have received global attention, others not. But expect over the coming weeks dozens and dozens of stories of promising compounds that kill SARS-CoV-2 in the test tube, almost all of which will eventually fall by the wayside.

The clinical techniques for managing those made most ill by Covid-19 are advancing rapidly. But the unprecedented flood of medical writing, published in record time, brings its own problems, with good peer reviewing in short supply. Some results are counterintuitive. I was surprised by an analysis that showed asthma sufferers to be under-represented in cases diagnosed with Covid-19: reasons are not yet clear, but it should give some comfort to those who have been worried that they were at higher risk, even as more definitive answers are sought.

Systematic research on the behaviours that sustain good Covid-19 responses still seems to be lagging. The COSMO initiative, which comes out of the World Health Organization’s Europe office, is a welcome exception. It provides a standard protocol and platform to collect data on knowledge, risk perceptions, preventive behaviours, and public trust during the current coronavirus outbreak. Already, national data collections are under way in Germany, Denmark and Argentina.

The stern policing that seems to undergird the current phase of the Australian Covid-19 response is not the same as the lasting response that will be needed until Covid-19 fades into the background. And that response will depend on the public’s willingness to police itself by communally developing new social norms based on good health literacy. We can be cosmopolitans and devise the new rules to live with one another, because the alternative is solitary, poor, brutish and short. •

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2 or 3 of the bakers have been closed, everyone down together. There were 7 deaths, all men. Arthur has been home from school 13 weeks. Syd had to board away from home on account of railway restrictions. All had to wear masks in shops and in churche [sic] and sit 4 feet apart — and only the minister unmasked.

By this stage of the epidemic, Singleton, 144 kilometres northwest of Sydney on the Hunter River, had been declared an “infected town.” A long battle to have the town’s plight recognised had finally succeeded, but the decision came too late to stop widespread infections and many deaths.

Jennie and her husband, George Colton Smith, had been managing the Singleton Aborigines Children’s Home since May 1910. The missionary couple sought to provide some semblance of conventional family life to the children in their care, some of whom had lived there since infancy. The home, established by local philanthropists, comfortably housed eighteen children. But since the Aborigines Protection Board had taken over its management from the Aborigines Inland Mission in 1915, the number was sometimes stretched to as many as fifty. The children were allowed to attend the local school, but when they turned fourteen the board placed them in “situations” — poorly paid or unpaid domestic employment.

“Restrictions were lifted last Wednesday,” Jennie told Percy. Of her younger children, sixteen-year-old Syd had just returned home after having boarded with a family in Maitland, where he was at school, and twelve-year-old Arthur had returned to the grammar school after five weeks at home. Seventeen-year-old Louise, her elder daughter, had been helping out at the children’s home since the restrictions had kept her from making her daily train journey to Maitland, where she was in her Matriculation year. To add to Jennie’s stress, nineteen-year-old Tilda was also back at home, recovering from typhoid fever contracted at Cummeragunja on the Murray River, where she had been working as an assistant teacher to Thomas Schadrach James, head of the Aboriginal school there.

Easing some of the pressure was the return of her Aboriginal charges to their schooling. “The children (home) went [to school] on Thursday, home five weeks, don’t you pity us with 34 of them. We received 2 more last week, tomorrow four more are coming which means 40.” The board’s demands were unrelenting.

The first Australian news of what we now call Spanish flu was published in the Sydney Morning Herald in May 1918. Some saw it as a German illness, a ruse by “Fritz” to delay or avoid defeat in the war against Britain and its Allies. By July 1918, though, it was clear the disease had caused a significant number of deaths among French and German troops and was spreading rapidly through England and Ireland. Journalists puzzled over the fact that this was a summer disease, unlike the usual winter influenza.

At the beginning of August the disease reached New York; at the end of October it landed in South Africa, with devastating consequences for the white and black populations. Some 1600 deaths were recorded there over a five-week period. In September, after India reported infections, news arrived, terrifyingly for the Australian government, that an infected ship from Canada, the Niagara, had reached Wellington in New Zealand. The epidemic occupied the press for the next three months.

Australia’s distance from Europe and the rest of the world bought it time, giving doctors a chance to learn about the illness before it struck. The disease’s symptomatology and progress were outlined by two New Zealand doctors in the Australian Medical Journal of 22 February 1919. The first case there had been diagnosed in September 1918 when the Canadian passengers disembarked in Wellington, New Zealand. It was of the “ordinary respiratory type,” they wrote, with catarrh in the upper air passages. By November the illness was showing up in lungs and then, “with explosive suddenness, a large proportion of the population was attacked; virulent cases streamed into the hospital in dozens and our resources were taxed to the limit.”

Contemporary accounts reveal the numbers of ill people to have been overwhelming. The NZ government took steps to restrict the illness, prohibiting church attendance and closing schools, barber shops and hairdressers. The population was advised to use mouthwash to prevent the spread of germs.

The Australian government had beefed up its Quarantine Department and commissioning new quarantine hospitals at each Australian port. On 27 November 1918 pneumonic influenza was proclaimed a notifiable disease for ships bringing troops back to Australia at the end of the war, and the many soldiers who showed signs of the disease were immediately quarantined.

For several months this strategy seemed to have succeeded. With deaths from influenza occurring only in the quarantine hospitals, some expressed hope that the pandemic would not break out into the community. But ships were continuing to arrive and the number of cases was increasing. The government recognised that it was only a matter of time.

That didn’t stop a Medical Journal of Australia contributor from decrying as sensationalist any talk of a wider threat and criticising estimates of a worldwide death toll in the millions. How could that be the case when London’s official figure for the seven-week period at the height of the epidemic totalled between 1600 and 1700 deaths? Despite reports of large-scale fatalities in New Zealand, he continued, the official return in the four weeks ending 2 December 1918 was “2458 cases across three of the four health districts.”

Even so, the press as a whole generally accepted that pneumonic influenza would eventually break quarantine and infect civilians. Reports of its virulence continued to arrive from New Zealand, Fiji and Samoa.

Public education had begun towards the end of November 1918. In an interview with the Sydney Morning Herald, a health department official recommended that people inoculate themselves, make use of “respirators” — face masks — and keep “as much as possible in the open air.” Soon a medical consultative council was established, consisting of the leading members of the British Medical Association, still the body representing Australian doctors.

Pneumonic influenza became a notifiable disease on 22 November 1918, a rule soon extended to ships coming into Australian ports. The NSW government appointed its director-general for public health, Dr Thomas Paton, to oversee an “administrative committee” made up of senior representatives from local government, employer groups, unions and retailers, along with the Ambulance Association and the National Women’s Council. The committee proposed public inoculation programs, the manufacture of masks at a shilling each, and what we now call social distancing. “If a person was four feet clear from the affected person’s face,” advised Dr Paton, “the former would not be affected by the disease.”

Federal and state governments met in Melbourne on 27 November. They agreed on measures to accompany infection proclamations at state and regional levels. The Commonwealth was authorised to take control of a state for the period the infection was active, and road traffic would be blocked at its border until a case broke out in the neighbouring state. Provision was made for specialised hospitals, vaccine depots and ambulance transport; volunteers and nursing assistants were organised. Theatres, hotels, picture theatres, race meetings, music halls, churches and schools would be closed. The medical, nursing and military arms of the Department of Defence would respond as needed.

By the end of December, quarantine had been broken. Of seventy-one deaths in the Blue Mountains town of Lithgow during the four months ending 23 December, the Sydney Morning Herald reported, twenty had been attributed to pneumonic influenza. The state was declared infected. Suspicious cases were reported in South Australia, which was also declared infected, and in Melbourne. Border controls were set up between Victoria, South Australia and New South Wales. People travelling between Melbourne and Sydney were directed to return home immediately, and on 25 January passengers travelling to Melbourne from Sydney were tested for the illness. The NSW government ordered all residents within ten miles of the Victorian and South Australian borders to wear face masks while they were going about their business.

The mayor of a city, town or borough, or a president of a shire, was designated as an appropriate health authority and could declare an “infected area” covering a radius of fifteen miles from a case. For the residents of Singleton, the process of gaining such a declaration proved to be surprisingly protracted.

Influenza’s tragedy didn’t extend to regions northwest of Sydney until May 1919, when figures began coming in from outlying areas. Young people, fathers and mothers, entire families were dying. Very young children were orphaned. Singleton’s Dangar Cottage Hospital, which had set up a specialised ward, was filled to its eight-bed capacity. Residents were “fighting the goblin of horror,” as a journalist for the Sydney Sun put it. There was no other way but through.

Hardly a home in Singleton was exempt from the illness. While it might have taken a mild form in many cases, it continued to claim victims. Businesses were depleted. Two of the town’s doctors were ill. On 3 July the editor of the Singleton Argus reported thirty-one deaths in the previous twenty-four hours and 106 newly diagnosed cases. Dr Alister Bowman, Singleton’s government medical officer and a frequent visitor to the children’s home, wanted the town declared infected. But the local council — always lax about these things, according to the editor of the Singleton Argus — was slow to take the matter up, perhaps preferring to believe that the decline in cases across the state meant that the country was getting “over the crest of such cases.” Even when the council did send a report to Sydney stating that the situation was “serious,” the health department still didn’t proclaim the town “infected.”

The editor of the Singleton Argus continued to plead the town’s cause. Matters might be improving in the rest of the state, he wrote, but that was clearly not the case in Singleton. Neighbours might be pitching in to help one another, but resources were low. The bakeries were closed because of illness, and so were the butchers and fruiterers.

The children’s home, long reliant on charity from local businesses, was deprived of the leftover bread and meat that had sustained it for almost a decade. Although it ran its own vegetable gardens and received rations from the government, the donated food had been vital.

Finally, on 12 July, the local council acted on Dr Bowman’s advice and closed the town. Schools had been shut since the beginning of July; now they were joined by theatres, pubs and other meeting places. The town asked the Country Influenza Administrative Council to authorise an emergency hospital at the local school. And finally, just as the epidemic was showing signs of abating, the Singleton Argus announced on 17 July, Singleton was officially “infected.” It was a bombshell for local people after all they had gone through.  A row promptly erupted in the town over the delay and the council’s muddled approach.

The closures had not happened when the town most needed them, as Dr Bowman later pointed out, before the cases began increasing exponentially. Yet remarkably, as far as we know, there were no infections or deaths at the children’s home. As Jennie told Percy, “I am glad to say we are all well, all had slight colds, nothing serious. Dad’s was the worst but all are doing well.” We can never know whether those colds were a mild case of something more serious.

We know little about the impact of the epidemic on Aboriginal communities. The Aborigines Protection Board’s minute books and reports made little mention of this illness that had closed state borders, business and schools. Reports published by the Aborigines Inland Mission in September 1919 noted the deaths of three people at Bulgandramine, southwest of Dubbo, and three at Moonacullah, near Deniliquin. In Walgett, the missionary himself had been affected and was using the schoolhouse as a hospital. More alarming is a note that a small camp at Denawan, near Walgett, had been “wiped out.”

After the pandemic, a campaign was launched to stop the Aboriginal residents of the children’s home from attending school. Perhaps feelings had changed when the home had been taken over by the Aborigines Protection Board and was no longer an object of charitable interest. A year later the Smiths were sacked, with George accused of unspecified “improper conduct.” Within a week, the board took steps to turn the home into an institution for boys; within three years the home’s premises, long run-down, had been demolished, a feature of the town’s cultural landscape lost forever. •

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About a third of the country’s intensive care beds are in the private system. The government is seeking to increase the national capacity from about 2200 to 7500 beds, which the minister said would be sufficient to meet the worst-case scenario.

His positive messaging may have been partly aimed at reassuring health workers, who have been following horrific accounts — particularly from the United States, Italy and Spain — of overwhelmed systems, shortages of personal protective equipment, and alarming rates of illness and death among health workers.

But at least one medical leader was not reassured. John Hall, president of the Rural Doctors Association of Australia, doesn’t think Australia is on track to have enough intensive care beds, and wants the military to set up field hospitals in areas of need, as has happened in Britain and elsewhere.

“If the international evidence is anything to go by, intensive care units across the globe have been overwhelmed, even when they’ve put good preparations in place,” he tells me. “I don’t think there’s any reason to think Australia is going to be spared.”

Hall is concerned about more than the number of beds; he fears that people in rural, regional and remote areas won’t get their share of beds and equipment. Private hospitals are scarce outside the cities, and intensive care units even more so. Yet non-metropolitan residents — especially in remote Indigenous communities — are especially vulnerable to Covid-19 because they are more likely to suffer from chronic health conditions and live in poor-quality housing.

“We’re concerned for rural Australians about that whole issue of the metropolitan beds being full,” says Hall. “They might have enough intensive care beds in total for the city, but that’s not to say that rural Australians will have access to those beds at any point in time. You might need a separate field hospital set up specifically for taking rural patients, so you’ve got guaranteed access for rural patients.”

Because they’re constrained by shortages of equipment, drugs and appropriately trained staff, rural hospitals have only limited capacity to ventilate critically unwell patients. Hall is worried by reports of some rural hospitals not doing enough preparation ahead of the surge in patients he expects to begin in late April or early May. He has observed a “delusional belief” among some that the novel coronavirus might not penetrate far into rural and remote Australia.

Even in the best of times, it can be difficult to arrange patient transfers from these areas to metropolitan hospitals, Hall says. During a pandemic crunch, retrieval services could easily be overwhelmed by demand at the same time as losing their valuable workforce to infection and illness. While work is under way to increase the capacity of retrieval services, he would like to see much more done, including involving the military in retrieval planning.

Urgent efforts are also needed to boost access to quality palliative care in rural, regional and remote areas. A recent statement from the Australian Covid-19 Palliative Care Working Group said palliative care is an essential component of frontline responses, and called for these services to be boosted as part of operational surge planning.

“There will be a significant demand for palliative care for some of the people who are elderly, frail and have multiple medical conditions, who don’t want to be resuscitated,” says Hall. “They may choose not to be retrieved or sent to an intensive care unit. Those people are going to need access to quality palliative care. We will need extra doctors, nurses, drugs to provide that. Many of these towns have only enough drugs and equipment to manage one palliative care patient at a time.”

At the National Rural Health Alliance offices in Canberra, chief executive Gabrielle O’Kane is also concerned about access to retrieval services and metropolitan intensive care beds, and is hearing from rural and regional doctors anxious about these questions. “Can rural health professionals be assured that there will be fair allocation of intensive care beds for rural people in metropolitan hospitals, should they need them?” she asks. “This situation has made it clear that there are considerable gaps in rural healthcare.”

The National Rural Health Commissioner, emeritus professor Paul Worley, is worried too. As he tweeted on 31 March: “Are you, like me, angry that rural Australia is having to fight Covid with one hand tied behind its back? The constricting rope is health workforce shortage. 61 GP vacancies in SA alone. We can’t just do more of the same. Let’s use this time to make our rural health system stronger.”

The Royal Flying Doctor Service is already feeling the impact of the pandemic. It transported forty-six patients with Covid-19, aged fifty-eight on average, between 20 February and 29 March, according to executive director Frank Quinlan. Transporting these patients takes longer and costs more because of the extra cleaning required for infection control.

Quinlan welcomed the news of public and private hospitals working together to expand capacity, and said the RFDS was also working hard to build its own capacity, bringing on additional resources, including locums, pilots, engineers, contractors and clinical crews.

“We’re planning for the worst and hoping for the best,” says Quinlan. “Planning for the worst means we have to consider the possibility that both aircraft crews and clinical crews could become ill and that will place pressure on already challenged resources. All of our planning has revolved around enhancing and building up that capacity.”

Quinlan believes it is too early “to be either comforted or alarmed” by trends in Australian case rates, but is encouraged by Australians’ response to calls for social distancing. “It is an opportunity for the community to take control of this crisis,” he says. “That creates the sense that we’re all working together.”

Under the deal announced by Greg Hunt this week, the private sector must act as not-for-profit organisations for the duration of the crisis, and open their books for audits. In return, governments are guaranteeing their viability during the life of the agreement.

Private hospitals will contribute 30,000 beds and 105,000 full- and part-time hospital staff, including 57,000 nurses and midwives, to the pandemic response. The Commonwealth was budgeting $1.3 billion for the arrangement, but the figure was not capped and, the minister said, “if more is required, more will be provided.”

Australian Healthcare and Hospitals Association chief executive Alison Verhoeven welcomed the deal as “a very necessary and sensible move.” “The whole arrangement is really good to see — state governments, the Commonwealth government and the private sector agreeing to work together in a really coordinated way for the benefit of the community.”

Stephen Parnis, an emergency physician at three Melbourne public hospitals and a former vice-president of the Australian Medical Association, says there can be no one-size-fits-all in bringing the sectors together, not least because of the diversity of private hospitals, which range from small day surgery facilities to fully equipped tertiary services.

To work most effectively, arrangements will need to be made locally, he says. “It may be that the private hospital takes on the standard hospital load to enable the public hospital to become sectioned off and treat Covid patients.”

A massive logistics exercise is under way, together with urgent efforts to boost health workforce numbers and extend critical-care training. Health workers, academics and communities are discussing the ethical dilemmas that lie ahead, spurred by reports from Italy and elsewhere of health workers left weeping and traumatised from having to make life-and-death decisions. When ten patients need lifesaving ventilation but only one machine is available, who is chosen?

At times like these, some groups — including disabled people and Aboriginal and Torres Strait Islander people — are at increased risk from both Covid-19 and systems that have a long history of causing them harm.

The Australian Indigenous Doctors’ Association, or AIDA, has received reports of Aboriginal people experiencing racism and exclusion from health services during the pandemic. It has called for Aboriginal and Torres Strait Islander patients to be tested and treated ethically and equitably for Covid-19. “Aboriginal and Torres Strait Islander Peoples’ lives, health and wellbeing cannot be put at risk because of underlying racism and prejudice,” says the association.

According to Janine Mohamed, a Narrunga Kaurna woman and chief executive of the Lowitja Institute in Melbourne, it is in high-pressure situations that non-Indigenous health workers are most likely to make kneejerk reactions based on embedded negative views of Aboriginal people.

“We have seen this already play out in our reduced access to transplants,” she says. “We know that Aboriginal people don’t get the same pathways of care. At this time, more than ever, cultural safety has to be at the forefront of health professionals’ minds. In September, when this pandemic is finished, what I don’t want to read is that Aboriginal and Torres Strait Islander people who needed intensive care were left to die. We have to do whatever we can to ensure that preventable deaths do not happen.”

Similar concerns are also worrying Bronwyn Fredericks, a Murri woman and Pro-Vice-Chancellor (Indigenous Engagement) at the University of Queensland, who stresses that Aboriginal and Torres Strait Islander people must be involved in developing pandemic ethical protocols for resuscitation and allocation of lifesaving interventions.

“I’m concerned for my parents, my partner, other family, friends, community members, and even myself,” she says. “I know that if medical interventions become rationalised and if we have coronavirus that there is the possibility we wouldn’t be offered lifesaving treatment if pitted against others, and that we would be offered isolation and palliative care instead.”

Fredericks is also worried that age could be a factor in determining access to care. “[This] fails to consider that that Elder in front of them may not just be a partner, or grandparent, uncle or aunt, but also be a precious and rare repository of language or law, music, art, medicine, knowledge, philosophy and more,” she says.

“They might be one of only a handful of people who hold this knowledge not just in the community, but in Australia and in the world… It needs to be asked, are we prepared for us, and the world, to lose this by rationalising lifesaving interventions based on availability of resources and age?”

While Fredericks welcomes the hospital deal in principle, she wonders about the implications for Aboriginal and Torres Strait Islander people. “The coronavirus itself doesn’t discriminate; it is society’s structures and people that do. The deal to open up private hospitals for all must also now ensure access for all too,” she says.

The perfect storm created by the pandemic is driving integration and cooperation across the health system in ways that were previously inconceivable. Suddenly, population-wide telehealth and other innovations that have been waiting in the wings for years are a reality. A government better known for health cuts than health innovation may go down in history as having introduced some of Medicare’s most significant reforms.

The Australian Healthcare and Hospitals Association’s Alison Verhoeven is keen to ensure the momentum continues beyond the pandemic. While some not-for-profit hospitals have a long history of working for health equity, Verhoeven would like to see the wider sector stepping up.

“At the moment, private hospitals support a population group that can afford to pay for their services,” she says. “What we have seen with this week’s funding announcements is a recognition that they are part of the public system, partly subsidised by the public purse, so they have an obligation to contribute to the health of the wider system.

“We hope that, longer term, private hospitals might continue to support some of that social obligation. It’s important that they engage in the dialogue that we need to have at a national level about supporting the health of the most vulnerable people in our community.”

More broadly, Verhoeven hopes the pandemic will also lead to wider societal changes, tackling problems that have been thrown into sharp relief by the pandemic, such as the casualised, insecure health workforce and the privatisation of essential services.

The Rural Doctors Association’s John Hall hopes the groundwork is being laid for lasting changes in the relationship between private and public health services. He would like the public sector to be more responsive and engaged in collaboration with private services, including general practice, radiology and pathology.

“My view is that public and private haven’t collaborated well enough in the past; we have seen that play out in the regions. For example, a private radiology firm might want to co-locate with a public hospital in a rural town but the negotiations have fallen over because the public sector is notoriously bad at working out collaboration with the private sector.”

Hall also describes public patients being transported long distances from regional centres for essential cardiac services that could have been provided by private services locally. This has often meant huge additional costs for patients and families because of the travel involved. “For a public hospital to use the private catheter lab is a really good example of where the private and public sectors could work together to provide an evidence-based service to the community,” he says.

Hall says this must be a transformational time in driving greater cooperation between health systems and services. “This is going to be a war for rural doctors and rural health services. We would like to see barriers broken down so everyone can put in their best efforts to win the war.”

In Tasmania, Geoff Couser, an emergency physician in public practice, questions whether it is appropriate to refer to a “private hospital system” at all. He prefers the term “federal public hospital system” given the large public subsidy the private sector receives through Medicare, subsidies for private health insurance, support from the Department of Veterans’ Affairs, and tax exemptions for religious institutions.

The pandemic crisis is a perfect opportunity for making clear that any sector receiving a significant amount of public money has a responsibility to contribute to the wider public good, he adds. “It is about getting the best value for that public money every step of the way. We need to have that sense of stewardship and responsibility on a fiscal level to taxpayers, and responsibility to patients.”

Couser also highlights inequities built into the system. Patients with private health insurance can tap into the “federal public hospital system” and get a colonoscopy next week, he says, while those relying on state public hospitals face long waits.

Despite apprehensions about what lies ahead, Couser is enjoying some relatively quiet time before the storm hits. Presentations in the emergency department are down, perhaps because more people are staying home. This has left time for preparation, and also reflection, including about how he hopes the crisis will bring transformational change for health systems and society more widely. “I hope that we will not waste the crisis,” he says. •

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The video might regrettably have been removed from her Twitter and Instagram feeds — pious advocates for the poor and downtrodden were outraged by its supposed insensitivity — but Madonna’s insight is backed by the academic heft of Walter Scheidel’s recent book, The Great Leveler, an account of economic inequality from the stone age to the twenty-first century. Drawing on income and wealth data over as long a period as possible, Scheidel makes the persuasive if dispiriting case that only mass-mobilisation wars, transformative revolutions, state failures or catastrophic pandemics have ever led to greater economic equality. (The shifts triggered by the second world war are a prime example.) Otherwise, elites use their capacity for rent-seeking, capital accumulation and state control to bend the system to their advantage.

The fear that the Covid-19 pandemic will indeed turn out to be a great equaliser is manifest in the increasingly desperate mantra that the pandemic will soon be over and everything will return to just as it was before. It is evident in Trump’s forlorn hope that churches will be full by Easter and the United States “opened up.” It’s also there in Scott Morrison’s repeated invocation of “the other side” at his 29 March press conference, and his hope that “businesses can get through and be there on the other side.” At least Morrison’s time frame was a more realistic six months.

It remains to be seen whether the economic changes necessitated by Covid-19 result in a lasting increase in equality. It will partly depend on how long the economic hibernation lasts, and that too remains to be seen.

As the week ended, chief medical officer Brendan Murphy cited tentative signs that Australia might be showing “a somewhat slowing of the growth in the epidemiology curve.” For the whole of March, Australia has been teetering on the brink of untrammelled community transmission. On one side of that threshold, every person confirmed to be infected is immediately isolated and vigorously followed up, with testing of all contacts who may have been exposed; combined with extensive testing of possible cases across the community, this approach can contain the epidemic spread. On the other side of the threshold, contact tracing becomes a drop in the bucket compared with the number of cases identified on the basis of their symptoms. Asymptomatic cases (about 60 per cent of SARS-CoV-2 infections) will likely never be identified, and the focus shifts to isolation and care of those who are sick.

In early March, Singapore pleaded for the “critical, clear, and present danger to all countries” to be recognised, and for its model of contact tracing and isolation to be emulated. At the end of March, the island state announced that its TraceTogether contact-tracing app would become open source and available to the world. Developed by GovTech, the Singapore government’s agency for digital transformation, the app uses bluetooth to enable voluntary users (620,000 Singaporeans so far) to keep track of all other users they come into close contact with. (Think of it as an always-on dating app, but with a very different aim in mind.) This data is stored anonymously and encrypted on the phone, though once the user is diagnosed with Covid-19 the data is unlocked by the Ministry of Health and all close contacts alerted.

The system depends on two things: a sufficient level of trust in government, and a recognition among potential users that they will benefit from being contacted quickly if they have been in close contact with a Covid-19 case. Unlike proposals elsewhere to use previously covert intelligence surveillance for Covid-19 tracking, the Singapore innovation seems to manage the balance between privacy and altruism. Already, the Covid-19 Digital Rights Tracker has identified nineteen countries where the pandemic has resulted in new digital-tracking measures, and most have eroded privacy significantly.

If (and it remains a very big if) Australia does become one of the few countries to contain the epidemic at relatively low levels, it will be a tribute to the public health system and to all those involved in this great effort. But the immediate relief will come with significant longer-term costs. Minimising the first wave of the epidemic will certainly mean that the capacity of critical care units in the health system isn’t overwhelmed, and that will minimise deaths. It will also mean that only a small fraction of the population becomes infected.

But those who become infected and then recover are the only part of the population guaranteed to be immune (and it is not yet clear whether that immunity will wear off over the course of months or years). For the remainder of the population, any new case of Covid-19 has the potential to set off a new wave of infections. As physical-distancing restrictions are relaxed, the potential for rapid spread will return, so rapid detection, isolation and contact tracing will remain critically important.

And as the world responds at different paces to epidemic control, a critical question will be when Australia deems it safe to relax entry restrictions from other countries. On Saturday China banned the entry of non-nationals following its eradication of new domestic cases; meanwhile, as was eminently predictable, the Covid-19 epidemic has become rampant in the United States. It may well prove feasible to allow travel between Australia and China long before Australia–US routes can be opened up.

Aside from contact-tracing apps, the technologies with the most immediate impact on the future of epidemic control will be in diagnostics. Already, new Covid-19 tests have appeared on the market, and alternatives to existing polymerase chain reaction, or PCR, tests are being developed or rolled out, including antibody tests that could be both rapid and self-administered.

Abbott has adapted and taken to market its toaster-sized ID Now diagnostic machine, though only in the United States for now. Like PCR tests, it tests for the genetic material of the virus; unlike PCR, which requires a thermal process to separate the strands of DNA, it operates at a constant temperature and is both compact and rapid. Abbott claims it produces positive results in five minutes and negative ones in thirteen.

Similarly, a new Covid-19 detection cartridge has been developed for GeneXpert, a rapid PCR assay machine small enough to sit on a desk and rapid enough to produce results in an hour. The GeneXpert machine has proved enormously useful in detecting TB — especially multi-drug resistant TB — in many developing countries.

When sophisticated diagnostics can be brought to local level they can transform the speed and flexibility of the local response. I vividly remember visiting a small health centre on Zimbabwe’s border with Mozambique about five years ago. The centre really was at the end of the road, a simple building run magnificently by two nurses on a shoestring. (Often they couldn’t report in to the district hospital because they had no phone credit.) But there, with its red light blinking in the corner, was a small PIMA CD4 machine that enabled on-the-spot diagnosis of the immune status of HIV patients. Instead of the usual procedure of sending samples off to a distant lab, which holds up treatment and monitoring, the whole process could be carried out locally (although it did rely on the systems that kept the machine functioning, with all its relevant consumables).

Beyond testing, the two wildcards in the evolution of this pandemic are treatment and vaccines. Not much has been heard in the past week about prospective treatments of those who become sickest with Covid-19, and that’s because a number of candidate treatment drugs are rapidly moving to trial phase. Shortcuts can be taken in treatment development, including speeding up regulatory approval, sharing information, and ramping up resources in the chain from basic science to manufacturing. But there is no avoiding meticulously designed and implemented trials to see whether a drug works. Medicine is littered with drugs that showed initial promise either in the test tube or even in initial human trials, but turned out not to be effective or even to worsen the disease.

A number of new vaccines are also well on the way to trialling, and they too will need careful assessment. Among the proposals to speed this process up is a call for approval of “human challenge” trials for Covid-19. Once a candidate vaccine is found to be effective and safe in animal models and first-stage human trials, it is normally tested in a larger-scale Phase 3 trial on people who might be exposed to the pathogen. These trials need to be large enough and last long enough to capture sufficient numbers who might have been exposed and detect differences in infection rates between vaccinated and unvaccinated trial groups. One way of speeding that up is to deliberately infect the trial group and then see how many of those receiving the vaccine develop the disease compared with those receiving the placebo.

In this case, the argument for a human challenge is that the risk of catastrophic infection will be minimal in a young and healthy group of subjects. That may well be true, but the risk will not be altogether eliminated. It’s hard to see an ethical argument for human challenges when the spread of Covid-19 is still rampant and large-scale exposure to the virus likely — but that may change if a vaccine is only ready for trial after the rate of new infections has died down.

From health systems to economic responses, clear pathways are emerging and many of them point to greater equality. Equitable income support, distributed diagnostics and open source solution software are all pointers to a communal, global levelling.

The “new normal” has become a dreadful cliché. Try Giorgio Agamben’s “state of exception” instead. It may give a better sense of both the possibilities and the dangers that lie in that liminal space, the brink on which we are teetering. •

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An ethical framework for dealing with the pandemic has international, national, community and personal dimensions. They play out in the familiar conflict between the needs and desires of individuals and of the group, and in the ability of the well-off, and well-off countries, to get more benefits than the disadvantaged. Decisions made by policymakers in times of crisis, and how the community responds hold up a mirror to our national ethos. Do we like what we see?

The World Health Organization sees three broad ethical issues. Who gets priority access to healthcare resources? What are the obligations of healthcare workers in light of the risks to their own health? And how do we balance necessary isolation and travel restrictions with protecting the rights of individuals? When a pandemic has dramatic economic impacts, that list should also include the question of who gets financial assistance. Affordable childcare options, internet access and room to work at home create a gulf between rich and poor.

Some of the ethical issues should be relatively straightforward. We need to ensure that some groups of people aren’t more likely to get tested than others simply because of their status or connections. We need to keep cracking down on people who flout instructions about social isolation and quarantine, especially when the capacity of certain groups to protect themselves and their families is already compromised by the essential work they do — not just as doctors, nurses and carers, but also in transport and delivery, cleaning and food services, and garbage collection. Hoarding, too, is anything but victimless during a pandemic.

The thornier ethical dilemmas arise when the number of seriously ill people requiring acute care rises to a level at which hospitals and healthcare facilities cannot cope. That has been the case for several weeks in Italy and is increasingly the case in New York City.

In Australia, the government and its advisers have provided reassuring advice about the ability of hospitals to increase their surge capacity, and the rationales for how we can flatten the curve to avoid the pressures on intensive care. But if the most worrying scenarios were to play out, Australian hospitals would not have the capacity to accommodate possible demand, and some types of care — specifically intensive care, ventilators and respirators — would need to be rationed. This would not be a discretionary decision but a necessity, and the level of rationing would increase if significant numbers of healthcare workers were infected.

Efforts to increase testing and social isolation will come to nothing if a similar level of investment is not put into protecting healthcare workers in hospitals and carers elsewhere in the community. Yet daily there are stories about the severe lack of appropriate personal protective equipment. This adds to the stress and anxiety of people who face the constant risk of infection and worry about their own families. At their extreme, the shortages could have the dreadful consequences highlighted by stories from Europe.

In deciding who gets access to rationed care, the overriding principle will be one of utilitarianism — maximising the benefits produced by the scarce resources — in the knowledge that available intensive care treatments are by no means guaranteed to produce the desired outcome.

In the United States, a conversation is already taking place in public about how to ensure, when lifesaving resources are scarce, that hospitals have consistent, transparent guidance for patient care. These “crisis standards of care” prioritise the survival of the group over the survival of the individual patient during disasters. But although the US Centers for Disease Control and Prevention has outlined general principles, it’s up to individual hospitals, health systems and states to decide policy. The result is a patchwork system, with states including New York and Minnesota having drawn up detailed guidelines for allocating resources but others having yet to confront these tough issues. If the pandemic and ventilator shortages get as bad as the worst predictions, some envisage palliative care being offered to people who might have survived with intensive care.

In Italy, the peak body for intensive care medicine has published a grim guide stating that “resources may have to be used first for those with a higher probability of survival and, secondly, [for those who have] the most years of life left, and offer the maximum number of benefits to the majority of people.” Others reach the same conclusions. “If we give scarce treatments to those who don’t stand to benefit (and have a high chance of dying anyway), then not only will they die, but those with higher likelihood of survival (but require ventilator support) will also die,” says Lydia Dugdale, director of the Center for Clinical Medical Ethics at Columbia University. “It’s not fair to distribute scarce resources in a way that minimises lives saved.”

In Australia, rationing has been mentioned in passing, but whatever expert discussions are taking place are out of public view and don’t involve public consultation. In drawing up guidelines and making these decisions, hospitals and doctors will consider the number of co-morbidities, the severity of respiratory failure and the probability of surviving prolonged intubation — factors that are generally linked to the patient’s age. But as medical experts both in Australia and overseas have noted, the primary criterion for rationing should be the chance of survival, whatever a patient’s age.

Being on life support in intensive care is challenging even for young, previously healthy people; patients often require fifteen to twenty days of ventilation and then a slow weaning. Intensive care is hugely resource-intensive, involving sophisticated equipment and large numbers of trained staff. Even the process of intubating a patient to go on a breathing machine presents a major infection risk to the doctor involved.

If a patient in these circumstances is not doing well, is it ethical to give the ventilator to another patient with a better chance of survival? Who would make that decision and what would guide them? This question might be hypothetical now but could become real in a very short time.

Little discussed is the extent to which the use of resources for treating patients with Covid-19 limits the treatment of patients with other medical conditions. Patients will continue to present with trauma, heart attacks, strokes and even complications arising from seasonal flu, and they too will need intensive care and ventilators.

The challenge of balancing the needs of Covid-19 patients and patients with other serious conditions applies also to medicines. Media hype about the possibility of treating coronavirus infections with chloroquine, pushed along by Donald Trump in the United States and Clive Palmer in Australia, has led to international shortages of a drug normally used by patients with serious conditions like lupus and rheumatoid arthritis. Here in Australia, people have purchased asthma medications in case they need them, reducing availability for people with chronic respiratory diseases.

The life-and-death decisions that rationing will force will be made more difficult if doctors are hamstrung by unnecessary procurement failures and shortages, if the system is rife with access disparities for some segments of the population, and if there is insufficient support and guidance for how such decisions should be made.

International organisations like the WHO and the OECD have called for a global effort and international cooperation to tackle the coronavirus pandemic. However, a pandemic inevitably means that countries look inwards to their own needs. President Trump’s policies have worsened the problem in the United States. Developed nations are all reeling from their own disease burden, which has been exacerbated in some countries, including Australia, by a lack of forward planning that leaves them facing shortages of testing reagents and kits as well as medical equipment. The situation will be much worse for developing countries.

In the weeks ahead, will the world be willing to share resources, as China has done for Italy? Or will there be isolationism, as seen in reports that the Trump administration was seeking to buy a German vaccine “only for the United States”? Will Australia look to see what help it can offer to Papua New Guinea and Pacific island nations? And who will ensure that the millions of people in refugee camps get the help they need as coronavirus spreads relentlessly?

The American College of Chest Physicians’ statement on care during pandemics and disasters makes the case that focusing on ethical principles is not a luxury but an obligation, necessary to engender trust and alleviate moral distress and burnout in providers. Trust is in short supply these days, as scarce as personal protective equipment for healthcare workers; clear principles can go some way towards restoring it.

That is why Australia needs explicit guidelines for how it behaves internationally, nationally and at the community level when needed resources are scarce. These must be ethically grounded, transparent, publicly developed, effectively communicated to all, and regularly reviewed. Because one day history will hold us accountable for what was done and why in this time of pandemic disease. •

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Singapore learned from that bitter experience, and is now being applauded by journalists and politicians across the world for its response to Covid-19. The government’s prompt and thorough imposition of social distancing — and even its Big Brother–style contact tracing — is the envy of health authorities across the world.

I was living in Singapore, researching a book, during 2003 and vividly remember the government’s slow response to SARS. I watched the epidemic unfold day by day and could see that the response was woefully inadequate up until at least halfway through the crisis.

The outbreak began on 13 March 2003, but it was not until 20 April 2003 that the government started taking it seriously. During those five weeks, the government lost valuable time that could have kept the death toll below the thirty-three lives that were eventually lost.

During the first phase of the crisis, I attended a government-sponsored anti-SARS rally in Singapore. The local authorities put up a small marquee in a housing estate, set out hundreds of seats side-by-side, and hosted the family-oriented event in the high afternoon humidity. The throng listened as government-sponsored speakers (not doctors) gave lectures on the risks of contagion. Social distancing didn’t occur then — nor a week later, when the same marquee hosted a crowded concert with a local band.

This rudderless period only came to an end when SARS threatened Singapore’s aristocracy: the family of its founding prime minister, Lee Kuan Yew. Kwa Geok Choo, wife of Singapore’s first prime minister and mother of the current prime minister, was rushed to hospital with a fever in mid April. Although she was quickly diagnosed as SARS-free, the scare galvanised the government. Lee Kuan Yew, still a member of cabinet, kickstarted the response by creating two ministerial committees (“combat teams” in the government’s parlance) to handle the crisis, sidelining the health minister and putting the response on the most serious footing.

Once the government focused, it learned quickly. Thermal-imaging scanners were set up at the airport and at the bridge connecting Singapore with Malaysia. Like everyone else, I wasn’t allowed to enter a public building without a temperature check. Schoolchildren had their temperatures taken every morning and any child with a fever was sent home immediately. Some measures were more theatrical than practical, designed to build awareness and change personal habits, but the media and government conveyed a clear and consistent message.

When I wrote about my experiences in a book about health policy in the Asia-Pacific a couple of years later, I noted that the SARS experience meant that Singapore was likely to handle the next threatened epidemic much more effectively. Singapore introduced stringent quarantine laws and protocols, enforceable by large fines and public humiliation. The Communicable Disease Centre, once a rundown, low-tech facility designed to cope with HIV/AIDS, now includes state-of-the-art isolation wards.

Now, the military, police and myriad other social instruments are geared to track the movements of suspected disease carriers, and those who they might have been in contact with. And the uniquely Singaporean system of social monitoring has been expanded to facilitate routine temperature taking, at short notice, of people with high fevers.

But while Singapore learnt from its experience, recent signs suggest that it risks letting politics undo much of its good work. Last week prime minister Lee Hsien Loong set the worst example by going on a walkabout through his constituency, only to be mobbed by a crowd of supporters seeking some of the — wait for it — hand sanitiser he was distributing. The walk, which took place during an uptick in Covid-19 infections, is likely to be a prelude to calling a general election in or near May, a year earlier than required.

Regardless of the conduct of Singapore’s politicians, though, Australia and the rest of the world would do well to learn from the actions of the city state’s service and health professionals. Covid-19 is a much more serious threat than SARS and the cost of dealing with it will be much higher.

It would have been better if the Australian government had sent out clearer messages about the pandemic weeks ago. Singapore has shown how the threat can be managed, and no doubt Australian policymakers have been watching closely. •

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Any route back from, or through, the abyss will be hard. Neutering Covid-19 is essential to minimising the pandemic’s human toll and economic hit, each measured in lost lives. A further test lies in the variegated nature of the emergency: global and national, and not just threatening health, livelihood, business, finance or governance, but all of these together. Europe’s states are stretching to their max, with no certainty that will be enough.

In Britain’s case, early caution has given way to urgency as the silo-busting scale of the challenge dawns. The government’s initial strategy projected four phases in tackling the virus: “contain, delay, research, mitigate.” Its public faces were the chief medical and scientific officers, Chris Whitty and Patrick Vallance, flanking Boris Johnson and giving the prime minister the ballast that he can’t help but seem to lack.

The pair’s kindly gravitas made even stark detail and advice sound reassuring. Then, a fortnight ago, though it seems years, came a perceived stumble over “herd immunity” — the notion that harmless infection at scale among the fit populace would safeguard the whole, allowing more gradual management of the epidemic by “flattening the curve” and thus keeping deaths to (it was whispered) around 20,000.

The theoretic case was marred by uneven (or outright poor) messaging. Some critics baulked at the idea in principle, others noted the contrast with Singapore, Taiwan, South Korea and Hong Kong’s proactive coordination, a lesson from SARS in 2002–03: “test, trace, isolate.” Equally, Britain’s resistance to the incrementally tighter lockdowns of European states made it seem an outrider nearer home. Scientific disquiet and media debate were prompting hints of a change when its accelerant materialised: a paper by the mathematician Neil Ferguson and colleagues at the MRC Centre for Global Infectious Disease Analysis, published on 16 March to immediate alarm and refocus.

Drawing on Italy’s medical trauma, its data modelling found that a staged approach would result in Britain’s health services being overwhelmed, and a death toll of perhaps 260,000. The policy priority had to be suppression of the virus, not mitigation:

Perhaps our most significant conclusion is that mitigation is unlikely to be feasible without emergency surge capacity limits of the UK and US healthcare systems being exceeded many times over… [Thus] epidemic suppression is the only viable strategy at the current time. The social and economic effects of the measures which are needed to achieve this policy goal will be profound… [Even] those countries at an earlier stage of their epidemic (such as the UK) will need to do so immediately.

From that Monday, directives — initially poised between advice and command — tumbled over each other at the now-daily briefings: self-isolation of the over-seventies, social distancing, home working, school closures, venue shutdowns (pubs, restaurants, theatres, cinemas). Since these measures would push many businesses and workers towards liquidation, chancellor Rishi Sunak announced £330 billion (A$664 billion) of loan guarantees to keep Britain’s largely service economy afloat. His acclaimed budget’s £12 billion to fight the epidemic, a week earlier, was already a distant age.

The blizzard of initiatives culminated on Friday with two more bazookas and a depth charge. After talks with business and unions, Treasury’s “job retention scheme” committed to paying 80 per cent of employees’ wages (up to a monthly £2500, or A$4970) for three months, plus sick pay to the self-employed and welfare supplements. Some details are still to be nailed down.

By then, so punch-drunk were newshounds that the Bank of England’s launch of £200 billion in quantitative-easing bond-buying and an interest rate cut to 0.1 per cent were barely noticed outside the financial pages. These few life-changing hours also saw the lightning creation of a 320-page coronavirus bill with bracingly wide statutory powers (for example, detention of miscreants or the mentally ill to enforce lockdown).

Over five extraordinary days — surely destined to produce a companion to John Lukacs’s classic Five Days in London, May 1940 — health, financial, business and governance emergencies melded. And a further, intimate emergency joined them, for the cumulative effect of the PM’s daily checklist was to impose on families and individuals across the land an obligation to reconfigure their lives for an indefinite period. “Unprecedented,” rare in this old country’s political discourse, had its moment in the sun. Only the 1940 crucible of the “people’s war” had vague plausibility as an analogue, not just via its jumble of mythicised memory.

A colossal week had already called forth a touch of martialism in a Britain always ready for the parade ground. Johnson declared “war” on the virus and pledged to “defeat” the “invisible enemy.” Then his Dad’s Army–ish “send coronavirus packing,” harmless as it was, let slip his bonhomous urge to test tonal etiquette, reprised in a wayward quip promoting ventilator output as “operation last gasp,” which many affect to find enraging.

More intriguing was the glow around hitherto mundane “key workers,” evidently a capacious bunch going well beyond the uniformed, badged and suited (with even some journalists passing muster). The British state has often looked threadbare over these two decades, at times an outright failure. This latest spine-stiffening exercise, forced by impossibly acute domestic demands, incorporates its own version of herd immunity.

By last weekend, the country’s twin paths — stepping into a new economic era while approaching a door into the medical dark — were palpable. Yet daytrippers lured by bright weather packed rural scenic spots and London parks were still in la-la land, their blithe spirits at last pushing a brittle Number 10 towards quasi-curfew. Johnson’s live Monday evening broadcast, delivering its you must stay at home mantra with passable high seriousness, was as stern as this natural libertarian can manage. (“The way ahead is hard… Join together to halt the spread of this disease, protect the NHS, and save lives.”) The exceptions to staying in — buying food, medical need, essential work, a lone bout of exercise — were clearer than the compliance regime. But the twenty-seven million–plus who watched on TV alone, almost half the population, could have no doubt about the main point.

Hours earlier, the coronavirus bill, its terms and two-year lifespan agreed with opposition parties and awaiting assent by the Welsh, Scots and Northern Ireland assemblies, was given sober treatment by a depleted Commons before passing without a vote. After the House of Lords’s brief scrutiny and the Queen’s sign-off, it grants ministers “wide and robust powers” (provisional as they are intended to be) to subdue Covid-19. The second week of this latest British-style revolution — for such it is, only three months after the previous one — had begun.

These volcanic events, their perilous background fortifying social unity insistently cultivated by broadcasters — have eased the political temperature. A YouGov poll released on 24 March put Johnson’s favourability rating at 55–35; Ipsos MORI on 19 March showed 48–41 satisfaction with the government (the first such positive score since 2010). A tilt to the Conservatives is plain. But incumbents often benefit when a crisis breaks, and such findings could well change as pressures on health staff and equipment shortages rankle, and Labour’s new leader (probably the London lawyer Keir Starmer) gets a chance to shine.

In play are two other factors: bubbling fury at the government’s early dithering or inattention over Covid-19, and confidence that the state’s massive interventions (several possibly irreversible) presage a decisive left turn.

The former links scientific appraisal of strategic failings to personal weaknesses of leadership, in particular those of Johnson and Dominic Cummings, the PM’s driven, sometimes abrasive senior adviser. Their reckoning is keenly anticipated, as much as Tony Blair’s ever was over Iraq. Their many enemies’ visceral loathing, hitherto ineffective as a political tool, can now draw on epidemiological expertise. That said, the politics of science around Covid-19 is complex and dialogic at many levels, the environment fluid, arguments unsettled. The chips may fall in ways few expect, just as they have in other areas over Britain’s last five years.

The latter puts fresh wind into sails tattered by four election losses, even vindicates the Marxist determinism of the Jeremy Corbyn–John McDonnell circle at the very moment it leaves the stage. Bliss it is in this dusk to be an ageing revolutionary. Their optimism is reinforced by centre-right marketeers who back Sunak’s splurge. But only the Telegraph’s Ambrose Evans-Pritchard grasps the dialectic. He is scornful of Number 10’s “staggering ineptitude” over the pandemic and hails the chancellor’s “executive action befitting the wartime threat that we face” while declaring: “To avert socialism, we must briefly become socialists. We must spend whatever it takes to save free market liberalism.”

What will remain of an economy if the shutdown lasts up to a year, and how the state will keep things ticking, are moot. People everywhere, the bedrock of society, are going to be co-shapers in any outcome. The last paragraph of the report by the team led by Neil Ferguson (he now in self-isolation after being infected) makes a version of the same point:

However, we emphasise that it is not at all certain that suppression will succeed long term; no public health intervention with such disruptive effects on society has been previously attempted for such a long duration of time. How populations and societies will respond remains unclear.

All this because a tiny viral agent composed of proteins and nucleic acids became a transformative force to beat them all. The WHO’s Bruce Aylward strikes an uncommon note, but the right one: “This is a new disease. Respect it and learn as it evolves.”

Covid-19 has barely got started. Here as elsewhere, the information deluge’s endless instancy can act as an infectant of its own, blocking awareness of time’s, and life’s, true rhythms. The thought struck home for me on that pivotal day, 16 March, during leg-stretching early-evening fieldwork in six large supermarkets on the fringes of a northern English city, each one clean out of the same everyday staples: pasta, rice, oatmeal, flour, eggs, soap, toilet paper. There was no supply shortage or interruption of delivery, I was told: it was just that some patrons were over-buying.

Such behaviour is not “panicking,” writes the psychiatrist Simon Wessely in that day’s Financial Times, citing 9/11 and the 1918 influenza epidemic to exemplify his case: “We have been warned to prepare ourselves for the [likelihood] of spending two weeks in self-imposed isolation. Stocking up on necessities is… a rational and appropriate response.”

True enough, but those vast bare shelves jolted me into recall of a 1960s joke from communist Poland. A customer at Warsaw’s Smyk emporium asks if this is the cheese section. “Nie, prosze panę, this is the department where we have no sausages. The department where they have no cheese is upstairs.” I could recite the differences in my sleep, but in that moment of psychic dislocation all I could think about was equalisation, and the cunning of history. The years fell away. I had become that customer.

Only a fortnight ago, but it seems an aeon — and that, like its correlatives above, is part of the problem. In this respect, Britain’s share of the global pandemic really is the new Brexit (a word I had hoped to avoid). With the enigmatic Covid-19 in rapid transmission, a repeat of the last four years’ manic inertia will hasten genuine disaster. Soon, these weeks may well come to resemble the “phoney war” whose mental force field was brutally vaporised in 1940 as the actual conflict became all too real. •

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Then the world turned upside down.

As the Covid-19 coronavirus spread from Italy into France, Macron proposed a change of dates for the Tahiti summit and then postponed his trip. I wavered, thinking I could still interview ordinary people rather than presidents and prime ministers. But with airlines cancelling flights and governments closing borders, the decision was soon out of my hands.

French Polynesia’s representative to the French National Assembly in Paris, Maina Sage, returned to Tahiti on 7 March. Four days later, French Polynesian president Edouard Fritch announced that Sage was his country’s first confirmed case of Covid-19. She had sat on a parliamentary commission in Paris with French culture minister Franck Reister, who was one of five members of the National Assembly soon confirmed with the virus. Tested on her return to the Pacific, she was diagnosed with Covid-19 and isolated at home. At the time of writing, French Polynesia is in lockdown, with twenty-five infections a fortnight after the first confirmed case.

The relative isolation of small island nations should provide natural protection from global pandemics, as long as quarantine systems and border controls are in place to monitor arrivals. It’s no small irony that the first confirmed cases of Covid-19 occurred in French Polynesia, Guam, Hawaii and New Caledonia, all of them American and French colonial dependencies (apart from Papua New Guinea, these territories also had the highest rates of HIV infection during the AIDS pandemic). The first coronavirus-related death in the Pacific was announced in the US territory of Guam on 22 March.

Infections have now been confirmed in Fiji and Papua New Guinea, and other island nations are likely to report cases soon.

Naturally people in the Pacific see parallels with the impact of the global influenza epidemic after the first world war. The New Zealand ship SS Talune travelled from Auckland to Apia, the capital of Western Samoa, in November 1918. On board were passengers suffering from a highly infectious pneumonic influenza, known as Spanish flu. Although the ship had been quarantined in Fiji, sick passengers were allowed to disembark in Samoa. An estimated 90 per cent of locals were infected and 22 per cent of the population died.

Today, health departments across the region are urgently sharing basic information about handwashing, social distancing and dealing with coughs and sneezes. But personal hygiene is constrained in countries where easy access to running water and sanitation is limited, especially in outlying rural areas and peri-urban squatter settlements. According to the Pacific Community, “approximately 45 per cent of all Pacific islanders continue to live without access to basic drinking water facilities and some 70 per cent live without access to basic sanitation — the highest of any region of the world.”

While many communities are still unaware of the enormity of the pandemic, years of work to prepare for natural disasters and climate change provide an invaluable base to build on. As I’ve reported in Inside Story, extensive efforts have been put into establishing community disaster committees, mapping local vulnerabilities, engaging women and young people, and developing culturally appropriate community education. The value of this work can be seen today: in the Fresh Water settlement on the outskirts of Port Vila, for instance, community leaders have rigged up bamboo poles to store water for handwashing where individual households lack soap and running water.

When reports emerged of mass infection on the Diamond Princess cruise ship in Japan and the Grand Princess in the United States, Pacific governments moved quickly to ban such visits. Then, in late March, Tuvalu, Nauru, Tonga, Vanuatu and Samoa all declared states of emergency, with other countries to follow.

On 8 March, the Republic of Marshall Islands took the unprecedented step of banning all flights into the country. What seemed an extreme step is now a commonplace measure, as countries close their borders and airlines cancel flights. But the collapse of the global aviation industry poses particular challenges to island nations: national and international carriers are a vital economic lifeline, carrying tourists, imports and exports, development workers and migrant labourers. The decision by Australia and New Zealand to close their borders created problems for the many islanders who must transit through Sydney, Auckland or Brisbane to reach home, but both governments are now waiving the fourteen-day quarantine period for some Pacific citizens to transit.

Pacific seasonal workers face a particular challenge. Many have travelled to work in the largest members states of the Pacific Islands Forum — in New Zealand, under the Recognised Seasonal Employer program, and in Australia, under its Seasonal Worker Programme and Pacific Labour Scheme. Employers in Australia are pushing for their visas to be extended, but social justice and workers’ rights are not high on the agenda.

As Henry Sherrell and Peter Mares have highlighted, this international labour mobility comes at a time of structural shift in the Australian economy towards temporary migration. More than 1.8 million overseas migrants now live in Australia on temporary visas, including New Zealand citizens who are visa holders with work rights under the Closer Economic Relations agreement. Countries like Samoa and Tonga receive more than a quarter of their GDP from remittances sent by their citizens working overseas. With massive job losses in Australia, will temporary labour migrants be welcome again?

As in Australia, interruptions to air and maritime transport, loss of tourism and increased health spending will damage island economies in coming months. Rural communities have the advantage of being able to continue farming and fishing, but other key industries will shed waged jobs. In Palau, Vanuatu and Fiji, for example, more than 40 per cent of GDP comes from the tourism sector. The loss of revenues and remittances will create added pressures on governments already forced to budget for increased health spending. Many countries and territories lack health infrastructure, equipment, qualified personnel and the crucial laboratory equipment to analyse tests on site. Papua New Guinea and some other countries have had to send Covid-19 samples to Australia for analysis, adding delays to diagnosis and treatment.

Even as Australia and New Zealand hunker down, support is needed for health systems in the region. Both countries are jointly funding the Pacific regional coronavirus response plan of the World Health Organization, which includes the WHO Joint Incident Management Team in Fiji. The regional technical agency, the Pacific Community, is the lead agency for public health in the islands region and is working with donors to provide funding, training and support to national governments.

But as borders close and each nation faces its own crisis, Pacific governments will bear the brunt. Even as the first cases are confirmed, governments are dealing with myriad tasks: acquiring laboratory and personal protective equipment; setting up screening services at airports; identifying isolation and quarantine facilities; and developing case management protocols and public awareness campaigns. The danger remains that the spread of infections may overwhelm the health systems of many smaller island states, which lack specialist medical staff and even intensive care facilities at their main hospitals.

Takeshi Kasaim, WHO regional director for the Western Pacific, says that Pacific nations face two major challenges: “First, healthcare facilities could rapidly become overwhelmed, even with a relatively small number of Covid-19 cases. This means that health facilities may not be able to focus on treating the most vulnerable and severe cases. Another major risk is that people with even mild symptoms may come to the health facilities, potentially amplifying the virus’s spread by infecting other patients.”

These weaknesses in public health systems were highlighted by a measles epidemic across the region during 2019. Samoa was worst hit, with eighty-three deaths and 1860 hospitalisations by year’s end, but another 661 cases were reported in Tonga, Fiji, American Samoa and Kiribati. The chair of the Pacific Islands Forum, Tuvalu prime minister Kausea Natano, stressed that people should ignore anti-vax propaganda circulated on social media: “In order to prevent further outbreaks in the region, I want to ask all our Blue Pacific family to heed the advice of your governments and health professionals, and get vaccinated against measles as soon as possible.”

The Covid-19 pandemic will stretch out for months, testing government and community capacity. Under the Coalition, Australia’s aid spending has increased in the Pacific (at the expense of development assistance to Africa and South East Asia). But the shift of resources towards multibillion-dollar infrastructure programs has come at the cost of funding for health services. As Labor’s shadow international development and Pacific minister Pat Conroy has argued, “Total health funding to the Pacific between 2014 and 2018 was cut by 10 per cent. So, while we’re providing some short-term assistance to deal with this crisis, it’s on the back of significant cuts to health assistance to the Pacific.”

Although Labor has been supportive of most government responses to the pandemic, Conroy has been sharply critical of the minister for international development and the Pacific, Alex Hawke: “He’s missing in action in terms of basic provision of public information,” says Conroy. “Minister Hawke is the public face of the government’s Pacific Step-up, and unfortunately he’s in witness protection.”

In the most brutal way, the coronavirus pandemic highlights the reality that the greatest security threat to island nations arises from environmental threats rather than the risk of armed conflict. The Pacific Islands Forum’s 2018 Boe Declaration captured the theme with its call for “an expanded concept of security inclusive of human security, humanitarian assistance, prioritising environmental security, and regional cooperation in building resilience to disasters and climate change.”

Despite Donald Trump’s crude attempt to rebrand Covid-19 as “the Chinese coronavirus,” the pandemic will redefine this regional security debate.

The circulation of misinformation about Covid-19 is yet another challenge throughout the region, given the widespread reliance on Facebook and other social media for news. Pacific media organisations are valiantly trying to support public education efforts while continuing to critique government preparations and messaging.

The same challenge faces the Australian media, which normally reports only briefly on crises in neighbouring Pacific countries, but is now likely to focus even more closely on domestic coverage. This will be exacerbated by the Coalition government’s constant funding cuts to international broadcasting in recent years. Six years ago, Inside Story reported on the gutting of Radio Australia by the Abbott government. The national broadcaster sacked experienced journalists with deep networks in the Pacific and years of experience across the region, then shut a number of foreign-language services. In January 2017, the ABC closed its short-wave broadcasting service — a penny-pinching decision taken without surveys of listeners in Melanesia reliant on short-wave rather than digital broadcasts.

Alongside the billions being allocated to the Covid-19 response in Australia and New Zealand, we could make a vital regional contribution by expanding information services to the region through radio and online. Even as the ABC withdraws its correspondent from Papua New Guinea, the decision to remove geoblocking on ABC iView is a useful step, allowing Pacific islanders to access news and information services. Radio Australia staff have taken great initiatives, such as the new children’s program Pacific Playtime, broadcast across the region every Friday morning to help families in social isolation. More can be done, drawing on the expertise of Pacific journalists on the ground.

Another crucial task is to mobilise and educate faith organisations about the pandemic. Across the Pacific, most people are regular churchgoers (or in Fiji attend church, temple or mosque). The “mainstream” denominations — Catholic, Methodist, Anglican and Lutheran — are now joined by a diverse range of evangelical churches and American-style Pentecostal sects.

This diversity of theological doctrine adds complications to the response to Covid-19 — a problem already seen with the religious response to global warming, the status of women and gay rights. Many people in fundamentalist church congregations have challenged the need for action on climate change, for example, citing biblical injunctions like God’s promise to Noah after the Flood: “Neither will I ever again smite every thing living as I have done” (Genesis 8:21). In contrast, mainstream theologians use the story of Noah and the ark as a parable of the need for preparedness and human agency.

The same debates will play out in coming weeks and months. Some fundamentalists will likely portray Covid-19 as God’s punishment for (add favourite sin here). Other denominations will be more active in responding to the virus. The Pacific Conference of Churches has already invited member churches to limit mass gatherings and change sacraments that involve personal contact or sharing the communion chalice. As one church leader joked, “God will protect us, but He still wants us to wash our hands!”

Meanwhile, the extent of the social and cultural impact is still sinking in. What happens to kava and rugby? How will schoolchildren fare with limited options for online schooling? Will official pronouncements be translated into local languages? How do you keep safe when you can’t afford soap and tissues?

Yet today’s lockdown has parallels with other crises in the region. During the war on Bougainville in the 1990s, life was transformed for people living behind the blockade. The lack of antimalarial drugs and medical care took a heavy toll, tragically undermining maternal and child health. But these years were also marked by innovation and creativity. Cars were kept running using coconut oil instead of petrol, electricity was generated by mini-hydro schemes and biofuels, and imported food was replaced with locally grown, nutritious produce. Courage was displayed by health workers like Sister Ruby Mirinka, who dodged the PNG defence force’s Australian-supplied helicopters and patrol boats to bring medical supplies from the Solomon Islands to Bougainville.

The spirit of self-reliance and confidence forged during those days was reflected last November when 97.3 per cent of the population voted in support of independence for Bougainville. Mirinka served as a member of the Bougainville Referendum Commission that supervised the vote.

As the islands region faces months of uncertainty and anguish, the pandemic will reveal the fault lines — of class, race and gender — evident in every society. But the experience of coming months will also forge a confidence and capacity to tackle other global challenges. There will be no return to business as usual. Around the world, governments are throwing billions of dollars into health and welfare services, transforming jobs and workplaces, discussing nationalisation of essential industries, creating government and industry task forces, and drawing on scientific expertise to guide policy. Isn’t this the way we need to tackle climate change, which the Boe Declaration describes as “the single greatest threat to the livelihoods, security and wellbeing of the peoples of the Pacific”? •

The post “God will protect us, but He still wants us to wash our hands!” appeared first on Inside Story.

With things so serious, and changing by the hour, the risk of falling into a gotcha moment is even greater. “But last week you told Australia we wouldn’t be restricting…” says the triumphant interviewer to the struggling politician who, for once, is trying to be honest and not avoid the question.

That’s because this pandemic is different. What politicians think is necessarily changing from day to day, and being responsible leaders they must rapidly adapt. The key to understanding Covid-19 is uncertainty.

The same uncertainty exists among health practitioners. When we try to predict the course of this disease in individuals we have little to go on. Same for the epidemiology. How quickly will it spread? How contagious is it? What measures can reduce the spread and what impact will they have? We can only make semi-informed estimates.

Behind us, we have the experience of the 1918 influenza epidemic, the SARS epidemic and other recent outbreaks, the Middle East respiratory syndrome coronavirus, other respiratory viral illnesses, and the lungs’ generic reaction to insults, known as adult respiratory distress syndrome (ARDS). But this coronavirus is different. So far, the smartest technology has little to offer.

This is where we need to rely on human beings rather than gadgets. Luckily, the international intensive care community has a long history of communicating well with each other through journals, conferences and direct contacts. I receive scores of personal communications every day sharing the experience of colleagues around the world.

We know the coronavirus is extremely contagious and has a higher mortality than normal influenza. It mainly affects adults, and the severe cases are usually among people over the age of seventy and those with chronic health conditions.

This means that normal hospital beds have little or nothing to offer the majority of sufferers — unless it is to enforce isolation, as authorities have done in Singapore. Until the disease progresses, we have no specific treatment; once it does, patients will usually be admitted to an intensive care unit, where the aim is to keep them alive while their bodies mobilise their defences and defeat the virus. Of all the cases of Covid-19 so far, between 5 per cent and 16 per cent have reportedly become serious enough to require admission to an ICU. Those figures are subject to uncertainty, of course, but for planning purposes they give Australian hospitals some indication of the task ahead.

This pandemic has encouraged an even greater sharing of information among intensivists across the world. So far, the information has come mainly from colleagues in China and Italy. As I write, the most cited intensive care journal in the world, Intensive Care Medicine, has just published up-to-date guidelines put together by thirty-six experts based on experience so far. Some of the most helpful information has come from Lombardy, a region in northern Italy. The epidemic has been especially grave in Italy. Intensive care is very well developed there and Milan has been at the forefront of how to treat severe lung disease using optimal artificial ventilation strategies.

Our lungs consist of large and small airways leading to millions of tiny air sacks, or alveoli, where gas exchange occurs. In certain patients, the virus attacks the alveoli. When the body defends itself by mobilising the cells and chemicals that fight the virus, an inflammatory response occurs and fluid pours into the alveoli. This is the same process that occurs in the upper respiratory tract, causing a runny nose; in the case of the alveoli, though, the consequences are far more dangerous. An alveolus full of fluid can’t take up oxygen and excrete carbon dioxide, and so the patient gradually becomes hypoxic, or short of oxygen. Trying to move the heavy lungs up and down, he or she becomes increasingly distressed.

If you are unfortunate enough to be in this situation you will be admitted to hospital and most likely to intensive care. The staff treating you will be dressed in personal protection equipment: a special mask if performing procedures, otherwise an ordinary surgical mask, gloves, gown and a face shield or special goggles. The ICU will be divided into a treating environment, a donning area (for putting equipment on), a doffing area (for taking it off) and a clean support area. Ideally, this will all occur in rooms with negative pressure to keep the pathogens isolated.

The severe bacterial infections common in ICUs often affect many organs in the body, including the heart, kidneys and liver. Circulation to these organs is severely disturbed and blood pressure drops, often requiring complex support for each vital organ. When an infection is accompanied by a decrease in blood pressure and abnormal circulation, it is known as shock, or — in cases where organisms are the cause — septic shock. Coronavirus may be different, with its major impact confined to the lungs, at least in people under fifty. But the data so far is variable, with some reports showing that other organs are affected in up to 35 per cent of patients, depending on their age and chronic health conditions.

ICU treatment can have some influence on the outcome of individual cases of Covid-19, but mortality will be largely determined by a patient’s age and underlying state of health. The first management strategy is to provide more oxygen to patients who are hypoxic. To provide more oxygen and assist breathing, oxygen can be delivered under pressure using specially sealed masks, called non-invasive ventilation, or NIV. This can be done in the emergency department or occasionally in specially configured wards of a general hospital. NIV is often all that is required when the patient is hypoxic.

But most hospitalised patients will rapidly become worse. A plastic tube will need to be placed in the windpipe, or trachea, and connected to a ventilator. To make ventilation more efficient and maximise oxygen delivery, most patients will need to be sedated and have their muscles paralysed. The aim is to maintain the body’s oxygen levels using ventilatory strategies while minimising damage to the lungs. This approach is well known to intensivists.

Of the 1503 patients recently treated in ICUs in Milan, 94 per cent were artificially ventilated and about one-fifth of those had to be “proned.” This involves turning patients onto their stomach, rather than having them sitting up, to improve ventilation and help correct the hypoxia. Of course, caring for patients in that position presents practical difficulties, but well-tried manoeuvres and strategies exist to optimise their care.

Despite optimal artificial ventilation, some patients continue to worsen and become more hypoxic. One more intervention is available: extracorporeal membrane oxygenation, or ECMO. Blood is taken out of the body and artificially oxygenated via a specially designed membrane before being returned to the body. ECMO devices are relatively scarce, and they require a considerable increase in staffing levels and expertise.

Using these approaches, very few Covid-19 patients under the age of fifty will die in the ICU. But what are the challenges for older patients, especially those with existing health problems and those over seventy, who are more likely to become critically ill? So far, regions with heavy caseloads have had to increase their number of ICU beds by moving to operating theatres, recovery areas and other parts of hospitals where the high technology is available. China and Italy have had to rapidly build new areas to accommodate ICU beds, and many countries face shortages of protective clothing, trained staff and ventilators.

With limited resources, will we need to triage patients who are older and already in very poor health, and therefore have a poor prognosis? Intensive care units around the world already do this. If patients near the end of life have little or no chance of recovery, it is generally considered inappropriate to place them on life-support machines.

Maurizio Cecconi, president-elect of the European Society of Intensive Care Medicine and a practising intensivist in Milan, has said that the triaging criteria for admitting patients to intensive care has not so far changed. The data from Milan show that many eighty- and even ninety-year-olds are being managed in ICUs.

But we are faced with the real possibility in Australia of not having enough beds, ventilators, staff and ECMO machines. What happens if a fit and otherwise well thirty-year-old is worsening and no bed or ventilator is available? In normal circumstances, even if my own hospital doesn’t have enough beds we can transfer a person to another hospital. The guidelines from the Australian and New Zealand Intensive Care Society suggest that admission criteria should reflect routine practice, and that similar criteria should apply across all jurisdictions and all patients. Whatever happens, we need to be transparent about the decision-making process and its justification in our dealings with other clinicians, patients and their families.

It is important to be aware that drugs have shown no impact on patients’ outcomes. It is always tempting to hope for a magic bullet, but so far none exists. What we do in intensive care is complex, requiring sophisticated technology, meticulous attention to detail, and team work, especially from nursing staff. It will be a matter of doing what we do every day as well as we can, and we in Australia are in a great position to do this. We are one of the leaders in the specialty of intensive care and provide care equal to or better than any other country. While we are confident that we will provide the best possible care, there is that word again — uncertainty. •

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Even though an HIV test had become available by then, not many people had so far been tested. With no effective treatment available, the prevailing view in the gay community was that it was better just to assume everyone was infected. That had two effects: it meant the responsibility to practise safe sex was shared between everyone, putatively infected or not; and it built solidarity between those becoming sick and those who were still well. For the healthy, it was either just a matter of time until sickness came or “there but for the grace of God go I”; either way, there was no room for judging those with AIDS.

Pandemics seem to have a rhythm. At first, after the alarm is sounded, it all seems far away and implausible. Then comes a phase of downplaying the risk — it won’t come here, it’s not so bad anyway — followed by a polarised debate about whether the official responses are too timid or too extreme (inevitably with economics as much in evidence as health). Then comes a full-on response (and however much we rationalise away the thought “We’re all going to die,” it finds ways of sneaking back). Then there is adjustment, resignation and coping with the new reality. And finally come signs that the worst is over, rarely building to a crescendo but usually to a creeping sense of relief. Perhaps only in retrospect do you realise the burden has been lifted.

In recent days an apocryphal Lenin quote has been doing the rounds: “There are decades where nothing happens; and there are weeks where decades happen.” This has been just such a week, with evidence of the exponential growth in the number of Covid-19 cases in Europe, the Americas and Australia. The core public health goal has coalesced around flattening the curve of the epidemic before health services become overwhelmed.

The most critical piece of information was the public release on 16 March of the Imperial College Covid-19 response team’s modelling of the epidemic impact of Covid-19 in Britain and the United States. It mattered not only because this team is probably the world’s best epidemic modeller, but also because the paper was intelligible as much to policymakers as to epidemiologists (and of course to armchair versions of both).

The modelling suggested that given what was known about the spread of SARS-CoV-2 (the virus name — the disease it causes is Covid-19), letting the epidemic spread with no response would result in 81 per cent of the British and US populations becoming infected, with 510,000 and 2.2 million deaths respectively. Mitigating the epidemic through case isolation, quarantining of affected households, and social distancing of people over seventy would halve the deaths but still result in eight times the current critical care capacity of both countries’ health systems. The only strategy that could keep demand for intensive care beds within capacity would involve suppressing the epidemic through school and university closures, social distancing for the total population, case isolation and household quarantine.

The Imperial College team modelled this approach for a maximum plausible duration of five months, building in an assumption that not everyone would comply. Crucially, the model suggested that the epidemic would rebound after measures were relaxed, to a peak nearly as high as would have been reached without the measures. They concluded that a partial relaxation would need to be mixed with a reinstatement of controls in certain localities as numbers started to rebound. All this is to prevent health system meltdown and buy time until effective treatment or vaccination becomes available.

In Australia, the week saw the progressive alignment of government and public health advice with a suppression strategy. The first signal came from the Australian Health Protection Principal Committee — the federal and state chief medical advisers — whose 17 March statement included a graph showing the daily growth of the epidemic since the one-hundredth case was identified. It showed Australia on exactly the same path as Spain, France and Britain. Clearly, widespread community transmission was on the way, and a significant shutdown would be required.

The data on different national responses to Covid-19 is advancing in tandem with the pandemic. Adding to our sense of the success of the total shutdown in Wuhan and later Hubei Province in China is a growing recognition of the role hospital isolation may have played in curbing the epidemic there. Not only was movement curtailed, but those who tested positive to the disease were hospitalised in the temporary facilities thrown up in a matter of days. This type of isolation could obviously be more stringent than an instruction to isolate at home, and greatly restricted transmission from those with only mild disease.

China has already celebrated the descent from the peak of the epidemic, with zero new domestic infections recorded for the first time on 19 March. But the country is acutely aware of the possibility of epidemic rebound as new cases enter the country. It is too early to declare the complete success of an East Asian containment model, though. South Korea joined China in bending the curve of the epidemic, but has seen something of a resurgence in the past few days. Singapore kept numbers remarkably low but saw a worrying spike in infections on 17 March. Japan’s trajectory has been much flatter than others, but that may reflect low testing rates.

What has become much clearer in the past few weeks has been the extent of “covert” infections — the 60 per cent or so of infected people who have either no noticeable illness or hardly any, but who are likely responsible for the majority of onward transmission. For some, the answer is to test everyone, and the proof is the natural experiment of the town of Vò, where Italy’s first Covid-19 fatality led to the whole population of around 3000 people being tested. All ninety-five cases found and isolated in two rounds of testing recovered fully and new transmission was eliminated within a fortnight. Much as this account is cheering, it will be hard to replicate when it comes to larger and more diffuse population centres. And for the moment, the limiting condition is the availability of tests, with a worldwide shortage of reagents already affecting Australia’s capacity.

The most recent tranche of research funding from the Australian government has been directed at filling some of these gaps. The Peter Doherty Institute at the University of Melbourne is rushing to develop novel testing strategies that promise to greatly reduce the consumables needed. Meanwhile, tests for the antibodies produced by the immune response to exposure to SARS-CoV-2 have also been developed in the past month, and offer two advantages: rapid throughput and their capacity to detect people who have been infected but have recovered and cleared the virus, leaving only the antibodies as evidence of their infection. The latter is especially useful for epidemiologists attempting to gauge the full extent of the epidemic. Sydney company Atomo Diagnostics is hoping to adapt its current HIV self-test machine for Covid-19 antibody testing, a potential development that may have a significant bearing (as its prospectus carefully explains) on its current initial public offering of shares.

The trajectory of HIV testing is instructive. Initially, it was surrounded with caveats and admonitions: pre- and post-test counselling, rights protections, expert administration of the test by doctors and then by nurses. Today, counselling has been dispensed with (there was no evidence it made a difference — all people wanted to know was their test result), rapid HIV antibody tests are cheap (less than 50 cents) and can be administered with a minimum of training, and self-testing with on-the-spot results has proven to be feasible and free of negative consequences. You can order Atomo’s self-test kit online in Australia for $25 (and, in partnership with generics manufacturer Mylan, it is available for a lot less in developing countries).

The twenty-five years it took HIV testing to evolve to this point may be replicated in twenty-five days for SARS-CoV-2. Already, American companies are using ambiguous regulatory flexibility from the Food and Drug Administration to offer a mail-order testing service. Receive the test, mail back the self-administered swab samples, and they’ll text your results within forty-eight hours. Demand seems strong, with one company that offers the test for US$181 advising on its website when daily capacity has been reached.

Testing is at the pointy end of public disquiet concerning equitable responses to the pandemic. The steady drip of announcements of celebrities and politicians testing positive for Covid-19 seems to show that the well connected have no problems getting tested, while most Australians, unless they fit narrow criteria of probable exposure and illness, find themselves turned away. This will likely change, but if we are headed for infection rates of 30 per cent or more of the total population then the queue for testing will stretch out for a long time.

This pandemic strikes at a time when trust in government, social institutions and the media is low. Against this background, public health communication has a herculean task. Unfortunately, the core communication challenges for public health authorities — inconsistency and uncertainty — pull in opposite directions.

The Victorian government did not cover itself in glory when it exempted Crown Casinos from social distancing rules — only revoking this exemption this weekend — or when it failed to call off the Melbourne Grand Prix until the morning the gates opened. All it achieved was a cynical resignation to the notion that money trumps public health. Similarly, schoolteachers are justifiably indignant when social distancing regulations of four square metres for any gathering are manifestly not feasible in classrooms, yet schools are not closed.

Of course, all these decisions are trade-offs between calculations of epidemic spread, economic damage and social psychology. But if health authorities frankly admitted making these trade-offs on an uncertain information base, they would be excoriated for sowing doubt. Australia’s current solution seems to be to seek the maximum possible consistency from the chief medical officer flanked by politicians, and rely on the ABC’s Norman Swan to inject scepticism, confidence intervals and doubt as required.

There’s certainly plenty of uncertainty to go around. Why is the fatality rate in Italy so much higher than in Germany (or China)? Are younger people at significant risk of death, or aren’t they? Do ACE inhibitors for hypertension increase Covid-19 risks or not, and if they do, will the damage caused by people getting off these medications outweigh the potential reduction in Covid-19 risk?

The information is uncertain and the studies are under way, but in the meantime, as technology writer Venkatesh Rao points out, when the narratives desert us, we do the math: “That’s how you know everybody has lost the plot: everybody is tracking the rawest information they have access to, rather than the narrative that most efficiently sustains their reality.”

There can be pleasure in radical uncertainty, of course. It creates a “time out of time,” the numinous experience devoid of everyday calculation, familiar in studies of ecstasy whether religious or secular, sexual or transcendental. But when it is experienced on a mass scale, we fear that anarchy will break out.

The evidence from disaster studies is that chaos may be less likely than we assume. In 2008 the doyen of disaster sociology, Enrico Quarantelli, reviewed half a century of research into responses to catastrophe and disaster to lay bare six myths: that people try to flee in panic, that looting results, that those affected are dazed and passive, that necessary personnel abandon their posts to look after their families, that disasters have severe mental health consequences and that firm top-down control is needed.

Quarantelli found that the evidence, drawn from extensive accounts of a range of catastrophes and disasters, showed the contrary: panic was rare; in the few instances where looting occurred it was not indiscriminate but rather a response to specific pre-existing injustices; immediate and active responses emerged as soon as communities were affected; emergency personnel overwhelmingly played their role even if the needs of their families caused them stress and concern; mental health effects were mild and short-lived (and disasters can even have positive impacts on mental health); and central authorities were the source of most problems in disaster response.

While the media accounts of the aftermath of Hurricane Katrina suggested an outbreak of lawless despair, Quarantelli’s evidence paints a different picture:

What emerged on a massive scale were smaller informal entities and network linkages sometimes but not always anchored in pre-impact known groups. Their pro-social and very functional behaviour dwarfed on a very large scale the antisocial behaviour that also emerged. Improvisation and innovation took place because the everyday traditional routines could not be used or were ineffective in dealing with the problems that had to be addressed.

Crucially, though, disaster studies show these pro-social improvisations emerge when the disruption is perceived as a common threat, not as a conflict. Blame is not just an unproductive pandemic response, it is positively counterproductive. This is why president Emmanuel Macron solemnly declares, “We are at war with an invisible enemy.” Donald Trump has attempted the same pivot, last week characterising himself as a wartime president, but he and his administration seem unable to resist the temptation to blame the “Chinese virus” just like those who persisted in referring to AIDS as “the gay disease” while maintaining they were just “stating the facts.”

So there are choices to be made, and some of them may be good ones. Following the adage of never letting a crisis go to waste, the radical destabilisation in the wake of the onset of the Covid-19 pandemic suggests some solutions to hitherto intractable social problems. The US government found it could create an entitlement to sick leave, the British government has guaranteed lost incomes, and the Australian government boosted assistance to the unemployed (albeit as a one-off rather than an ongoing commitment). In the face of massive shutdown job losses, campaigners for a universal basic income are suddenly finding policy audiences much more receptive.

The extent to which the current crisis results in increased social solidarity and greater equality remains to be seen. The sight of empty supermarket shelves suggests pernicious and competitive individualism has more than a few adherents. But I prefer to have faith in the empirical evidence that ground-up solidarity building will be the predominant response.

The hardest thing to do in a crisis is to maintain a sense of perspective. It is one of the reasons pre-planning happens, which means that Australia’s current template draws on the plans developed to respond to potential pandemic influenza. Last week, as a member of my local hospital board, I participated in a committee meeting by phone in which the senior staff went through the organisation’s contingency plans. It was strangely comforting to hear about the planned responses at different degrees of epidemic escalation and know that for whatever scenario, a scaled response would be put in place. While triage seems an affront in any immediate personal health situation — I must have maximum care right now — it is a daily reality for health services even in the best of times.

The first peak of Covid-19 illness will pass. Rebounds will come. Meanwhile, extraordinary improvisation is happening for the good. The Victorian Infectious Diseases Reference Laboratory has achieved an unprecedented decentralisation of testing facilities down to local level, coming on stream this week. In the world’s densest precinct of biotech innovation, right next to MIT, Moderna’s vaccine candidate based on messenger RNA went into phase 1 human trials on 16 March — an astonishingly fast process using a new, highly designed and yet-to-be-proven way of conceptualising vaccine development. Since February, the Coalition for Epidemic Preparedness Innovations has pumped funding into seven candidate vaccine projects, including one at the University of Queensland. And last Friday the World Health Organization launched SOLIDARITY, a coordinated multi-country trial of four of the most promising treatments for Covid-19.

I don’t know of a similar catalogue of social innovations in response to Covid-19, but it would be good to have one: block by block, city by city they are undoubtedly emerging. I hold out no hope for a deus ex machina. But I do for the cumulative accretion of steps of solidarity, innovation and adaptation. That seems enough to go on with.

Meanwhile, in the service of amassing raw data, what am I reading?

• The World Health Organization’s updates
• Case report updates from Johns Hopkins University and the nifty graphs you can build yourself of selected country trajectories
• The Lancet’s Covid-19 resource centre
• Nature’s coverage
• The International Health Policies Network weekly update
• Somatosphere’s series, Dispatches from the Pandemic
• STAT’s coverage
• The Australian health department website and particularly the Australian Health Protection Principal Committee’s statements. •

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Epidemics of infectious diseases have continued to devastate affected groups in Australia. But these have generally been smaller (and often marginalised) populations, including Aboriginal and Torres Strait Islander people, injecting drug users and gay men. Except for brief periods, such as the early days of the HIV epidemic in the 1980s, mainstream Australia has largely been able to ignore these outbreaks. The viruses we have come to worry most about have been the ones on our computers.

Just like the Australian population, our health system has little experience in dealing with a crisis of this scale. The National Communicable Disease Plan, drawing on experience gathered by the Exercise Cumpston system test in 2006, has assisted in guiding the government’s response. But the realities of responding effectively to the virus have demonstrated the vulnerability of a fragmented, poorly coordinated and inequitable health system. The way it has met (or not met) expectations, so far at least, offers important lessons for our response to similar events in the future.

Health isn’t a solo event

Health policies and programs focus on changing individuals’ behaviour and treating disease and disability. But treating health much more as a team sport will be crucial to successfully combating the coronavirus pandemic. Developing strategies to halt the spread of this virus means thinking not only about how to protect our own health but also about how to work together to minimise its impact on the community.

A commitment to health equity is crucial. Like a soccer team with a poor defence, our abilities are only as good as our weakest players. A stockpile of hand sanitiser in the garage won’t protect you or your family if this means others will expose themselves to infection and become vectors of transmission.

It’s not just about being altruistic (although this is important). When it comes to health even the most selfish among us has an interest in helping others.

This perspective on health isn’t new, of course. It’s more than a decade since the World Health Organization’s Commission on Social Determinants of Health described the vital role in good health played by employment, class, social status, housing and other social factors. A commitment to acting on these issues was recently renewed by the WHO.

Yet, despite a multi-party Senate committee unanimously recommending that the federal government adopt the WHO report, Australia has not acted on any of its recommendations. In fact, some measures of inequity, such as wealth distribution, have worsened: the wealthiest one-fifth of Australians now own nearly two-thirds of all wealth, while the least-wealthy half own less than a fifth. Although there’s said to be “no better place to raise kids,” an estimated 1.1 million Australian children live in poverty.

Despite these inequities, the advice coming from health authorities seems oblivious to the circumstances of many Australians. People are asked to self-quarantine at home; patients arriving at hospitals are told to “return to their cars” and phone for instructions; it’s suggested that we stock up on two weeks’ food. No advice is provided for people who don’t have stable and safe housing, regular employment, a car, a mobile phone, internet access, the capacity to deal with a short-term lack of income, or the ability to purchase and store bulk foods. As lawyer Thalia Anthony points out in relation to prisoners, who are among the most marginalised populations in our community, this failure risks undermining the effectiveness of Australia’s response to the virus.

Fragmentation creates confusion

It goes without saying that viruses don’t respect borders. Cooperation and collaboration between the federal government and the states and territories is essential, but challenging when healthcare responsibilities are split.

For its part, the Commonwealth is responsible for primary healthcare, Medicare, regulation of therapeutic goods (including testing kits and protective equipment), aged care, the medical stockpile, and non-health policies including border control. The states and territories, meanwhile, have primary responsibility for the public hospital system, disease surveillance and quarantine (within their jurisdictions), ambulance services, and most community and social care.

Divided responsibilities inevitably cause gaps, fragmentation and confusion. Getting eight jurisdictions and the Commonwealth to agree on a joint approach can slow the response to a fast-moving and rapidly changing environment. As a 2004 Parliamentary Library research paper observed, “Overlapping Commonwealth/state responsibilities and divisions between clinical health practitioners and public health policymakers were identified as two broad problem areas in Australia’s national arrangements for responding to an infectious disease outbreak.”

During Australia’s response to the epidemic thus far, different governments have provided conflicting advice. People experiencing symptoms have been told to visit their GP, to call (but not visit) their GP, to ring Healthdirect, to self-monitor, or to go to a public hospital for testing. Communication between governments, GPs and hospitals has been inadequate, with GPs receiving inconsistent information about testing protocols and facilities.

“To take one example,” says the president of the Royal Australian College of General Practitioners, Harry Nespolon, “there has been confusion about the type of face masks that GPs need to wear… We are also getting different advice from the states and territories on the tests for coronavirus and who should be taking them — should they be done by a GP in a clinic or should they be done in a hospital in a negative-pressure room?”

This fragmentation is not just a practical problem. It also adds to the confusion and anxiety in the community and reduces trust in governments’ ability to coordinate an effective response to the pandemic.

Coordinated primary care must be a priority

Even if every other part of the health system worked perfectly (which of course they don’t), a primary healthcare sector — GPs and other frontline practitioners — that is under-resourced, poorly coordinated and not always accessible will seriously undermine the effectiveness of our response.

Over the past month it has become clear that Australia’s primary care system is poorly prepared to respond to a major public health threat. This is not the fault of the profession or a reflection on individual doctors and their staff, who are generally highly dedicated professionals doing their best under extremely difficult circumstances. But their efforts have been challenged by a flawed system inadequately resourced by successive governments.

Despite this neglect, governments have counted on GPs to deal with patients concerned about their symptoms or potential exposure, and to provide advice on testing and deal with other enquiries, all on top of their normal workload. Governments’ first advice to people concerned about the virus or experiencing symptoms was to “call your GP,” but their unrealistic expectations of what GPs can and can’t do have exposed the vast gap between the government’s idea of general practice and the reality.

Most GPs are either small businesses or employed by profit-driven companies. They have neither the resources nor the incentive to carry additional capacity — such as quarantine rooms and stockpiles of equipment — to deal with crises. Expecting a local general practice to meet the increased demands for healthcare during a pandemic is like expecting the corner shop to supply everyone’s food and household goods.

“I don’t know of any GP practices that would be capable of testing or seeing a suspected case,” Sydney GP Richard Nguyen told the Guardian earlier this month. “In our practice we have four consulting rooms plus a procedure room. We’d have to dedicate one room as an isolation room. And then you’d have to clean and disinfect the room — logistically it’s just impossible for several reasons, including that we don’t have the physical space.”

In the short term, our primary healthcare system can probably muddle its way through this crisis, largely because of the professionalism and dedication of GPs (and their practice staff). But it won’t be ideal. GPs will take risks, as healthcare workers often do with infectious diseases, and some will undoubtedly get sick. This is not fair to these doctors or to their patients.

Solving this problem means tackling the fragmentation and variability built into the present system and better integrating primary care with other parts of the health system. For years experts and health groups have advocated exactly this kind of reform. The 2009 National Health and Hospitals Reform Commission, for example, called for “strengthened primary health care services” and “the development of Comprehensive Primary Health Care Centres and regional Primary Health Care Organisations… to support service coordination and population health planning.”

Successful examples already exist, including innovative private practices and Aboriginal Community Controlled Health Organisations, and could serve as models for reform. Learning from them and building on the existing (but limited) Primary Healthcare Network infrastructure would strengthen the capacity of the primary healthcare sector to manage future public health threats.

Effective communication is vital

The Communicable Disease Network Australia’s National Framework for Communicable Disease Control was supported by health ministers from all jurisdictions after it was released in 2014. One of its key conclusions was that identifying “a credible and trusted leader” and providing timely, effective and consistent communications were vital during a health emergency.

During this crisis the government has failed to meet this goal in a number of ways. Information has been inconsistent, patchy and sometimes contradictory; key details about the virus and its threat to the community are perceived to have been withheld from the general public; and positions have shifted significantly on some key issues (travel bans, border control, the financial impact of the epidemic) within days and sometimes hours of official announcements.

Political leaders and health authorities have fumbled when answering simple questions and struggled to explain in precise language the reasons for seemingly conflicting advice. When the Council of Australian Governments announced that non-essential gatherings of more than 500 people should be cancelled, the prime minister stated that this did not apply to workplaces, childcare centres, schools, university lectures, public transport, airports “or things of that nature.” The most important messages about behavioural changes required to limit the impact of the epidemic (washing hands, minimising social contact) risked being lost in the confusion.

Efforts by the government to communicate with health professionals have been similarly inadequate. Doctors working at the frontline of the epidemic have described the government’s dealing with them as a “shambles.” The Australian Medical Association has called for authorities to start “singing from the same song sheet” and the Australian Nursing and Midwifery Federation urged the federal government to send “clear and consistent messages to the community in order to contain the rapid spread of the coronavirus (Covid-19) and ease growing anxiety, confusion and concern about this public health emergency.”

Compounding this problem has been the seemingly contradictory behaviour of political leaders. At the same time that the prime minister announced the ban on non-essential gatherings of over 500 people he also said he would be going to a rugby league match. People in hazmat suits cleaned the Parliament House office of home affairs minister Peter Dutton after he tested positive, yet chief medical officer Brendan Murphy said that the prime minister and other cabinet members who had been in contact with Dutton needn’t be tested or self-isolate. Despite the recommendation to adopt social distancing, the PM continued to be seen in close contact with other political leaders, journalists and advisers.

This degree of inconsistency is a serious problem for a government trying to persuade people to change their behaviour in ways that can seriously limit their freedoms. Advice that seems contradictory or frankly impractical (staying 1.5 metres from other people on public transport, for example) or that is not being followed by political leaders themselves undermines the credibility of the message and the authority of the government, and risks people ignoring it altogether.

Of course, communicating in this complex and rapidly evolving situation is challenging. Both under- and overreacting carries significant potential costs. Maintaining a balance between encouraging sensible concern among the community and preventing public hysteria is crucial.

It is understandable that the government focused on avoiding panic. As health promotion expert Daniel Reeders has pointed out, panic encourages a range of ineffective behaviour: it encourages panic buying; it can prevent people from processing what they read or hear, making it much harder to convey accurate information; it puts people in a “me-and-mine first” frame of mind at a time when collective action is required; and it can cause people to dismiss “emotionally dissonant” messages — such as health experts giving calm, measured advice — in favour of hyper-emotive rumours and conspiracy theories.

But it is also important to acknowledge the limitations of the authorities’ knowledge about health threats. As the WHO’s guide to Communicating Risk in Public Health Emergencies puts it, public communications “should include explicit information about uncertainties associated with risks, events and interventions, and indicate what is known and not known at a given time.”

“My biggest concern is people are not talking to their populations like adults,” says the WHO’s Bruce Aylward. “They’re cherry-picking the best possible survival rates [and] outcomes, the lowest possible incidences. You’re just going to compromise confidence of your population.”

These problems are not just a failure of communications but a failure of leadership, which is an essential component of effective risk communication. According to the US Environmental Protection Agency’s Seven Cardinal Rules of Risk Communication, trust and credibility are a spokesperson’s “most precious assets” when communicating risk information. “Long-term judgments of trust and credibility are based largely on actions and performance. Trust and credibility are difficult to obtain. Once lost they are almost impossible to regain.”

This is bad news for a government in Canberra already struggling with criticism over its handling of the recent bushfire season. The trust and credibility that it will lose as a result of its poor response in the early days of the coronavirus pandemic may prove impossible to regain.

Health literacy matters

Part of the communication challenge facing governments is the low level of health literacy in the Australian population. Good health literacy helps people make decisions that maximise their own health and that of others. Poor health literacy makes communicating complex messages and trying to effect behaviour change in a stressful environment even more difficult.

Data on health literacy in Australia isn’t great (which is a problem in itself) but the indications are that it is pretty poor. The most recent national data available from the Australian Bureau of Statistics, which dates from 2006, shows that only 41 per cent of adult Australians were sufficiently literate about health matters to meet the complex demands of everyday life. This rate was even lower for older Australians, with only 28 per cent of people aged sixty to seventy-four considered to have adequate levels of health literacy.

Among the health stakeholders who have recognised this problem is the Australian Commission on Safety and Quality in Health Care. It says that low health literacy can significantly drain human and financial resources and may be associated with extra healthcare costs of 3 to 5 per cent. The problem has been evident in the seemingly irrational response of many in the community to the pandemic, such as avoiding Chinese restaurants.

One of the greatest challenges has been to explain the urgency of slowing the transmission of the virus (or “flattening the curve”), a desired outcome of government policy but a difficult concept to explain.

Also important is health system literacy. When a system is experiencing dramatic increases in demand, it helps if people know where to go for information, advice and care. Talkback radio calls have made it clear that many Australians lack even a basic understanding of our health system. Callers described calling the national Australian Medical Association office for information about where to access telehealth consultations in their local communities, contacting their state health department for information on Medicare-funded services, and being frustrated when their local pharmacies didn’t provide testing services.

The public health system will always bear the burden

Despite the government’s (and the media’s) obsession with private health insurance, this crisis has made clear that it is the public health system we rely on when serious health risks emerge.

The coronavirus pandemic is the greatest health crisis our country has faced for a generation, and private health insurance is basically missing in action. Our annual investment of around $11 billion into this sector does not appear to have strengthened our overall capacity to respond to the pandemic in any respect. At all stages it has been the public health system that has stepped up to manage our response to the virus.

Our public universal insurer, Medicare, is funding bulk-billed and telehealth consultations for people at risk or showing symptoms of coronavirus. Public health microbiology laboratories developed the capability and capacity to detect and confirm cases following publication of the genome sequence for the virus at a publicly funded research institute. In Victoria, testing centres have been established at nineteen hospitals and health services, not one of which is private; nationwide, public hospitals are performing Covid-19 tests as well as treating people who are seriously ill with the virus, all at no out-of-pocket costs to patients.

Far from the “Better Cover, Better Access, Better Care” promised by the private health funds, people with private insurance are being left high and dry by their funds. Anyone who purchased private insurance under the illusion that a policy named “Security” or “Ultimate Health Cover” would be useful in the context of a major health threat would now be experiencing a major reality check.

As one reader of the health policy blog Croakey wrote, “I have maintained private hospital cover for many years because of a suspicion that the Lib-Nats would do away with Medicare if they could. Today I rang the largest, most modern private hospital in Perth and asked what they could do for me if I came down with Covid-19. The answer? Nothing, sorry, you’ll have to go to a public hospital, you can go as a private patient, we don’t have the facilities.”

International experience in responding to the coronavirus pandemic indicates that the countries with strong universal public health systems are having more success than those with a privatised and less equitable approach to healthcare. The message from this pandemic is that private health insurance is (at best) an optional add-on that doesn’t merit the resources it currently receives. If Australians ever needed convincing of the benefits of a strong and well-functioning public health system, this pandemic should be more than sufficient to persuade them. •

Many thanks to Dr Ruth Armstrong for her help with this article.

Jennifer Doggett is Chair of the Australian Healthcare Reform Alliance and an editor of Croakey.

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In the event, Trump’s prime-time address to the nation last week failed spectacularly to reassure Americans and unify the nation. Over the subsequent twenty-four hours, corrections had to be issued to errors in his statement, the European Union protested that it hadn’t been consulted about the new travel ban, and another early-morning collapse gutted the stock market. Then, not long after Trump claimed that testing had “been going very smooth [sic],” expert witness Anthony Fauci told a congressional hearing that it was “failing.”

This speech was followed by a hastily organised media event in the Rose Garden at which Trump announced a national emergency and touted his business links. The outcome was little better — the stock market rose but the public health messages were garbled. (“Trump is breaking every rule in the Centers for Disease Control and Prevention’s 450-page playbook for health crises,” said one public health expert.) The president also denied responsibility for coronavirus testing delays.

Trump and his advisers seemed to panic as they realised that the declining economy and lack of trust in his leadership on this issue could pose a threat to his re-election chances.

“Who would have thought?” the president had mused during a recent visit to the Centers for Disease Control and Prevention, apparently blind to the fact that he and his administration have ignored repeated high-level advice about the threat of a pandemic. In 2017, for instance, the global health security unit of the National Security Council, set up by President Obama after the Ebola crisis, advised that the threat of a pandemic was “the number one health security concern.” Soon enough, the unit was abolished, for reasons Trump can’t now explain.

A January 2019 report from the office of the Director of National Intelligence warned that the United States would “remain vulnerable to the next flu pandemic or large-scale outbreak of a contagious disease that could lead to massive rates of death and disability, severely affect the world economy, strain international resources, and increase calls on the United States for support.” Two months later the prestigious Washington-based Center for Strategic and International Studies predicted a coronavirus pandemic and worked through what the impact would be.

When it became obvious in January that the coronavirus had spread from China to the United States, the very defensible first response, and the one preferred by Trump, was to impose travel restrictions and institute incoming passenger screenings and quarantine. So far, so good — but the administration failed to follow through by enhancing readiness and creating a reliable surveillance strategy.

The first outbreak of coronavirus, in Seattle, was identified in sentinel surveillance work by independent scientists. But this type of monitoring, which has the potential to detect viral hotspots quickly, isn’t common, and restrictions on who could access the testing left public health officials blind to the spread that had already occurred.

Preparedness for the inevitable spread was hindered by Trump’s insistence on viewing coronavirus as an outside threat that was under control within the United States. Evidence also suggests that Trump didn’t take early advice about testing — which would inevitably have meant more cases were discovered — because he thought low infection numbers would boost his re-election chances. In any case, approved testing kits were not then (and are still not) available in anywhere near the numbers needed.

Several factors helped create the kit shortage. The Centers for Disease Control and Prevention chose to develop its own test for the virus and then, when this was found to be flawed, insisted on taking time to revamp the test rather than adopting the WHO test or allowing other US-based labs to develop their own. Only now is the availability starting to ramp up. But the daily number of tests remains limited and varies by testing facility, partly because of a shortage of key chemicals needed to run the tests. As Dr Fauci, the only straight talker on the White House coronavirus task force admitted, “The idea of anybody getting [testing] easily the way people in other countries are doing it — we’re not set up for that.”

This leaves the United States with two possible paths: to emulate South Korea, which appears to have reversed the outbreak, or to be like Italy, where the situation has deteriorated rapidly and healthcare rationing is proposed.

Realistically, the possibility of stopping the spread of the disease is now all but lost. As of 11 March, 7695 tests had been conducted in a population of 329 million people, whereas South Korea had conducted 189,236 tests in a population of 51.3 million. South Korea is now seeing a steady decline in the number of new cases reported each day.

The main goal now must be to slow the spread of infection, or “flatten the curve” using social distancing, quarantining, proper hygiene and other initiatives. These measures reduce the number of cases at any given time, easing the pressures on hospital services that have been assessed as inadequate for the task.

But it’s not only a question of the adequacy and appropriateness of the measures being introduced by the president and his coronavirus task force; it’s also about whether reliable advice will be adopted across a country in which so many people don’t have affordable access to healthcare and other social services.

“Stay home from work if you get sick,” says the Centers for Disease Control and Prevention. “See a doctor. Use a separate bathroom from the people you live with. Prepare for schools to close, and to work from home.” But many Americans don’t have health insurance, many more are underinsured or have substantial deductibles that have not yet been met. And many don’t get paid sick leave or care leave and don’t have the ability to work remotely.

A 2019 survey of private industry and state and local government workers found that while paid sick leave is nearly universal for high earners, the figure is just 31 per cent among people earning US$10.80 an hour or less. Some 33.6 million people have no cover, and a significant percentage of them work in the food industry and hospitality and have close interactions with many people.

After a meeting with the heads of some of the largest health insurance companies this week, Trump and vice-president Mike Pence announced that the companies promised to waive all co-payments for coronavirus testing and to extend coverage for treatment. But they didn’t mention that this agreement covers, at best, only around 240 million Americans; left out are the estimated thirty million people who lack health insurance, the forty-four million who have inadequate insurance, and the eleven million undocumented immigrants.

The picture quickly became more complicated. The day after the meeting, the health insurance industry group and individual companies appeared to indicate that some private health plans would still have cost-sharing requirements for the test.

Several Democrat-led states — including California, Missouri, New York and Washington — have ordered health insurers to cover the tests without cost-sharing requirements for their members. They have also made sure people covered by Medicaid are tested for free. Such initiatives are yet to be seen in Republican-controlled states.

Federal funds could be used to protect individuals from the costs of testing, quarantine and treatment in other ways, too, if only the administration chose to do so. Trump’s health and human services secretary could authorise states to expand Medicaid coverage to people with a Covid-19 diagnosis, as has been done in other emergencies. For people who are unable to pay their virus-related healthcare costs, the health and human services secretary, via the Centers for Disease Control and Prevention — which can authorise payments for testing, treatment, care and quarantine — can be a “payer of final resort.”

Meanwhile, the plunging US stock market has highlighted the economic ramifications of the pandemic and concerns about the administration’s inadequate response. By one measure, the entire rise in stock market value since Trump was elected has been erased in recent days. Trump has always claimed responsibility for jobs growth and a booming economy; now he must own the downturn.

A few days ago he promised a fiscal stimulus package of “dramatic” economic measures. But his key proposal — a temporary payroll tax cut through to the end of the year, estimated to cost nearly US$700 billion — was floated apparently without prior consultation and was very coolly received by Republican lawmakers and the president’s own economic aides. Since that pushback, he has evinced little willingness to pursue his other proposals, which include an infrastructure plan, paid sick leave for hourly employees, and help for the nation’s ocean-cruise industry and airlines.

Instead, the running has been left to congressional Democrats under House leader Nancy Pelosi and Senate minority leader Chuck Schumer, who have worked with Treasury secretary Steven Mnuchin on a multibillion-dollar economic relief package.

The package provides short-term benefits for people affected by coronavirus, including unemployment insurance, additional funding for food security for low-income children, and funds for family and sick leave. It would provide US$500 million for low-income women, mothers with young children and pregnant women who lose their jobs due to the virus, US$400 million for food banks, and a waiver of work requirements for the SNAP (food stamps) program. The bill also includes free coronavirus testing and a boost in Medicaid reimbursement to help states with testing and treatment.

Despite Mnuchin’s involvement, the White House equivocated for several days on the bill, with Trump apparently holding stubbornly to the idea of payroll tax relief. Pelosi’s leadership finally prevailed and the House passed the Families First Coronavirus Response Act, 363–40, late on Friday. The bill will go to the Senate this week, where support from Senate leader Mitch McConnell seems cool at best. He will be pushed into action because Republican senators campaigning for re-election don’t want to return home without having been seen to act — and because Trump now says, astonishingly, “Look forward to signing the final Bill, ASAP!”

Washington media report that Trump has grown increasingly irate as his attempts to contain the political fallout from coronavirus continue to fall short. He now recognises that the 2020 election campaign will be very different from what was expected just a few weeks ago.

In a response to Trump’s address to the nation, former vice-president Joe Biden highlighted how coronavirus has laid bare the shortcomings of the Trump administration. He spelt out a detailed roadmap for tackling the virus, emphasising the need for solidarity and championing science.

Eager as Trump might be to blame others for the current situation, he has directly and indirectly contributed in many ways. He has consistently sought to erode scientific expertise and cut funding for federal efforts to tackle epidemics internationally and within the United States. He and his enablers have sought to limit transparency, subvert data and minimise the importance of the issues. He continues to claim that the nation is prepared — that “we’re doing a great job with it. It will go away. Just stay calm. It will go away.”

It’s hard to believe a president who repeatedly contradicts his public health experts and blames everything on his critics. A current fact check lists twenty-eight ways Trump and his team have been dishonest about the coronavirus.

Innumerable examples show the importance to voters of how political leaders respond to national catastrophes. But, as a 2009 study showed, voters reward presidents for delivering relief spending after disaster strikes, rather than for ensuring preparedness — which means, theoretically at least, Trump still has time to respond to voters’ concerns and be rewarded. But given his inherent inability to fully grasp the issues, his unwillingness to take expert advice, and his narcissism, this is unlikely to happen.

Several commentators have described the coronavirus threat as “Trump’s Chernobyl,” arguing that prioritising ideology and myth-making during a crisis is, literally, deadly. Certainly, by putting his own beliefs above objective facts, Trump has tried to construct a reality that does not exist. Worse, scientific and public health experts have been intimidated and even muzzled and have too often failed to contradict him.

It is too soon to say if Trump’s posturing will result in unnecessary deaths and an economic recession. But the evidence to make that case could be on hand by November. If this happens, the incumbent could face a landslide defeat. •

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The government’s aim should be to shape public understanding and behaviour in a way that contributes to mitigating the spread of Covid-19. Backed by clear and effective policy planning and implementation, public messaging can be a highly effective way of mobilising populations to become stakeholders in damping down widespread “black swan” societal threats like this virus. Can the experience of governments overseas help Australian policymakers to do this as effectively as possible?

Authoritarian versus democratic responses

Because they can use coercive measures much more swiftly, authoritarian governments might seem to have an advantage over democracies when it comes to dealing with diseases like Covid-19. But there’s a clear caveat: pandemics require whole-of-society efforts, and that means the “authoritarian advantage” only kicks in when the iron fist has a velvet glove. Regardless of their political system, populations will only put up with aggressive quarantine measures, for instance, if they feel they have a stake, their basic human needs are still broadly taken care of, and their collective efforts are having demonstrable results.

Despite signs that China’s efforts are paying off, other nations have been reluctant to follow its tough example. China specialises in speed, scale and obedience, things that decentralised democracies find very difficult to match. But already Britain and other countries have been warning their publics that life may need to change substantially if efforts to flatten the Covid-19 epidemic curve fail, and that they should be prepared for constraints on their liberties and choices for the broader public good.

So far, Australia’s navigation has been broadly creditable. The federal government’s pandemic action plan needed to be amended to deal with the specifics of Covid-19, but that effort didn’t need to start from scratch. The immediate emphasis on detecting illness among people arriving from overseas helped buy time, and testing and tracing has helped identify those who slipped through the net and might start local transmission clusters. The government has acknowledged that surge capacity and supplying protective gear to frontline workers remain challenges. And it urgently needs to engage with general practitioners about their role in the battle, engage better with the general public about what part they can play, and coordinate more effectively with state and territory governments and other authorities.

Maintaining a balance between encouraging wariness and preventing hysteria is crucial, as the perplexing panic buying of toilet paper shows. The rush on supermarkets is an indicator of a level of public fear and a lack of confidence in government. Panicky behaviour like this suggests that the official response can’t afford to become complacent and take public compliance for granted.

Denial, delay and distrust: what not to do

Iran is the leading example of failed policy and flawed messaging. Tehran hid its Covid-19 outbreak until well past the point when doing so was rational, even if the primary goal was to protect the regime rather than the public. Members of the elite have been infected, and some have died. The country’s relatively robust health system is verging on collapse, yet the regime failed to use its brutal but effective power to prevent the movement of people. In fact, its messaging has only recently begun moving from “everything is fine” to “this is a challenge we will overcome,” and public trust has crumpled as a result. The government reacted too slowly in preventing dangerous behaviour, with the most chilling example being videos circulating of devout worshippers licking shrines in Qom in order to prove that their faith could overcome any virus.

Japan’s early responses to Covid-19 are another good example of what not to do. The Abe government badly botched its quarantine of the Diamond Princess cruise ship: not only were people still being infected while the ship was in lockdown, but authorities subsequently let twenty-three people go without testing them. And with Tokyo desperate to host the Olympics later this year — a prospect that looks increasingly unlikely — the government decided to keep official infection numbers down by testing as few people as possible. Coupled with the social distancing measures being rolled out throughout Japan, the recent decision to close schools in Hokkaido for two weeks makes clear that the situation is by no means under control.

Italy’s performance has also been poor. Because the government missed the chance to catch local infection clusters early, it was forced to take the aggressive step of quarantining the Lombardy region. Regardless, Italy’s disease burden has increased markedly, making its next step, nationwide quarantine, also virtually its last resort. The sheer number of cases Italy has exported to Europe and elsewhere makes clear that its infected population — like Iran’s — has been badly undercounted, dramatically eroding domestic and international confidence in the Conte government’s ability to rein in the outbreak.

Britain’s response to Covid-19 has been mixed. Concerns about the capacity of the National Health Service to “surge” against Covid-19 were reflected in a poll of 1600 doctors, which found that 99 per cent of respondents believed the NHS was not ready for the task. No doubt keenly aware that Britain has only 2.5 hospital beds per 1000 people, health secretary Matt Hancock announced plans to recruit an army of retired health professionals — nearly all of whom are in the age group most at risk of severe complications or death from Covid-19 infection. And whereas Hancock has tried to raise public awareness with a “catch it, bin it, kill it” campaign, he has also faced criticism for statements that seemed to suggest Britain was giving up on containment and preparing the nation to take the outbreak on its chin. For his part, prime minister Boris Johnson has faced questions about his lack of visibility during the crisis.

Forget China, worry about America

The United States’s Covid-19 response has been hamstrung by political infighting, a lack of coordination and a number of bizarre errors. Many Americans already distrusted Donald Trump’s leadership; many among his support base, as well as media organisations like Fox News, have continued to back him even when the advice he gives is dangerous.

Trump’s incoherent press conferences on the epidemic have revolved around boosting his image in an election year rather than reacting quickly with the best possible expertise. His decision to put vice-president Mike Pence in charge of the US response — a man whose belief in prayer and gay conversion therapy led to a massive spike in HIV infections in Indiana — seemed more about finding someone who could be blamed for failure than identifying the best candidate for the job.

Press conferences featuring Pence and Trump’s health and human services secretary, Alex Azar, have devolved into obsequious fawning over Trump’s leadership of the kind we associate with the world’s most autocratic regimes. Trump himself has continued to hold mass rallies, even referring to concern about the virus as the latest Democrat “hoax.” He demonstrated his wilful ignorance of the emergency by falsely claiming that a vaccine was mere months away, and also claimed that Covid-19 would vanish like a miracle. He asked a team of health professionals to prepare a strong version of the influenza vaccine (which treats a different virus altogether) to be used against Covid-19. And in a phone call to Fox News he seemed to suggest that the majority of Covid-19 sufferers could simply go to work as usual.

America’s disease coordination agencies have also reacted poorly. The recently defunded US Centers for Disease Control and Prevention, or CDC, in Atlanta has dropped the ball on several occasions, allowing the virus to circulate for at least six weeks. The CDC allowed a patient in San Antonio who tested positive to the virus to go home, only to hastily recall him. It rarely updates its public guidance.

Having eschewed the World Health Organization’s recommendations on testing in favour of developing its own field kit, the CDC discovered that its test was faulty. But instead of letting other jurisdictions develop their own tests, it simply stopped testing anyone who didn’t fit a very strict set of criteria: air travel to China, exposure to a known positive Covid-19 case, and all the known symptoms of a disease that often affects patients differently.

What made matters worse was that once the United States did declare Covid-19 a public health emergency, any new test needed to be approved by the US Food and Drug Administration. When an FDA official arrived at the CDC to inspect their initial test kits for contamination he was denied entry for twenty-four hours. We should be deeply concerned about the capacity of the United States to weather the epidemic.

Many commentators in the West have claimed the disease will be China’s “Chernobyl moment.” At the very least they foresee a Hong Kong–style flowering of dissent born of a public realisation that the Chinese leadership cares more about politics than the population. Above all, they stress that China cannot be trusted: that the Silk Road is a transmission belt for disease as well as development. Hence, this thinking goes, there is an urgent need for other nations to economically decouple from the People’s Republic.

These predictions are flawed. If anything, China’s ability to blunt the advance of Covid-19 will allow it to deepen its internal control, tracking and tracing a population that willingly signed up to forced quarantines, movement checks and colour-coded travel statuses. More than that, the epidemic has had a mobilising effect on the Chinese population, which the leadership in Beijing will exploit. China is likely to try to turn what should be a global PR disaster into a soft power coup, the gold standard model for containing major threats to societies.

For other countries, decoupling from China may make strategic sense in the name of diversification of supply, but precisely how and where nations will recouple remains unclear. China will be an integral part of the global recovery from Covid-19, in terms both of its experiences and of its capacity to keep global supply chains moving.

Success stories

So far it’s the countries that have combined rapid responses with effective public messaging that are weathering the storm of Covid-19 most successfully. Taiwan and Hong Kong are good examples, but Singapore’s response has been particularly noteworthy. Pragmatically, officials stressed from the outset that the government could not ensure complete safety. Instead, it focused on immediate isolation and forensic contact tracing of cases, along with consistent messaging stressing that it is a civic duty to seek assistance in the event of infection. As a result, local outbreaks are relatively well controlled.

South Korea’s misfortune was that its outbreak quickly reached the Shincheonji cult, a closed and secretive religious organisation, many of whose members are now contributing to the nation’s large caseload. But Seoul’s decision to test as many people as possible, combined with best-practice social distancing and a blizzard of information for the public, seems to have contributed to a declining infection rate. It has also provided a wealth of data about Covid-19’s attack rate, not to mention more reliable information about disease severity and mortality.

While China’s response has been criticised as overly draconian, it has clearly had a major impact in bringing infection rates under control. As a visiting World Health Organization team noted, China’s response combined aggressive control of population movement with rapid deployment of medical staff to hotspots, swift updating of treatment plan guidance, and the use of big data to trace infection spread and predict future outbreaks. This was not only effective in flattening the epidemic curve; it also arguably saved many lives and prevented the spread of the disease outside Hubei province.

Although these controls would be difficult to replicate in Australia, China’s approach is still instructive. Many Chinese citizens may not have believed official figures, and there was significant evidence of corruption, but centralised messaging ensured that citizens understood their roles and responsibilities in the plan to fight the outbreak.

The experiences of Singapore, South Korea and China all illustrate that no “one size fits all” model exists for responding to Covid-19. Singapore in particular can readily trace people within a very small geographic area, but a large-scale outbreak would threaten national stability very quickly. Australia probably faces the reverse problem: pockets of transmission in urban hubs that crop up quickly and require drastic action to contain their spread. Even if each nation is successful in mitigating its own outbreaks, though, the struggle against Covid-19 will continue to face the risks created by imported and sleeper cases.

Lessons for Australia

Enlisting broad public support with well-communicated information coupled with rigorously implemented policy will be critical to how well Australia emerges from the Covid-19 epidemic. A whole-of-society approach, not just a whole-of-government one, is fundamental. Drawing on the experiences of other nations will help considerably to target our response for the best possible outcomes. These ten points are therefore intended to identify what has so far worked well in other nations and apply it to an Australian context.

1. Messaging should be clear, transparent and, above all, agile. We still don’t know enough about Covid-19, but our understanding of case–fatality ratios, attack rates and vectors of transmission will firm up with more reliable data. This information should be shared as soon as possible, and officials should make clear why new approaches may differ from past practice. A national Covid-19 information centre should be established to share reliable, user-friendly information in a variety of media, as well as combating fake news.

2. Depending on the severity of the outbreak, it may be necessary to adopt increasingly tight movement controls. The reasons for each step in this process must be clearly spelled out to minimise confusion, and every effort should be made to avoid politicising unpopular decisions or crowing about government success. As the experience in Italy and Wuhan demonstrates, any decision to close off an area needs to be implemented swiftly to avoid people fleeing and potentially spreading the virus outside containment areas.

3. Australia’s messaging should draw the link between top-level decisions in the public interest and individual circumstances. Panic buying partly reflects a desire to preserve a degree of control. Maintaining public confidence in supply chains and the ability of government to maintain order will be necessary, but even more crucial is to enlist public compliance. Examples of risky behaviour should be outlined just as clearly as safe behaviour, with messaging deployed along the lines of “we will not overcome this challenge without your help.”

4. In spite of the best efforts of government, many individuals will resist official guidance out of a lack of trust. Government should therefore consider enlisting civil society champions to reinforce its messaging. This should especially be available on social media, where much of the public gets its news, as well as via conventional TV and print media.

5. Information vacuums will inevitably be filled by fearmongering and misinformation. This is especially true when reliable news is often paywalled whereas fake news is free and readily accessible. People come to rely on daily case counts and the location of victims, for example, so they can assess risk. This information can and should be provided without personal information being compromised. China and South Korea have successfully developed apps that show where cases and clusters are located, and similar tools should be considered in Australia.

6. Health services may become overwhelmed at the peak of an epidemic, and the national ability to enforce order may be challenged. Coercive measures can be effective in minimising rule-breaking if they are judiciously applied and communicated, including as a sensitisation measure before an outbreak deepens. Mandatory isolation backed by penalties have helped Singapore and China to maintain compliance; Korea, by contrast, vacillated on penalties before deciding to threaten Lee Man-hee, the leader of Shincheonji, with murder charges for covering up the spread of the virus.

7. The public is unlikely to tolerate buck-passing. Commonwealth–state relations may present legal and practical challenges to implementation, but the public will not be persuaded that interruptions to essential services are unavoidable problems of federalism. They will look to the Commonwealth to lead, backed by the best information from the states and territories. This underscores the need for a unified national effort to communicate what the public should do, and how and where individuals can seek help. Access to welfare payments will be crucial for casual and “gig” economy workers who decide to self-isolate, as will rent support for small businesses and other assistance for those cut off from their regular sources of income by quarantines.

8. Media and government catastrophising is unproductive — even though the public need to be sensitised to the likelihood of significant disruptions to their lives, as well as the potential for Australians to die during the outbreak. Messaging should therefore be as neutral as possible when conveying information about deaths and new infection hotspots, and the mainstream media should be enlisted to assist. Conversely, downplaying or softening information may lead to riskier behaviour or public disappointment if the situation worsens. Factual information based on the best evidence — even when it is distressing — can and should be communicated in the context of how society will be able to move to a recovery mode as swiftly as possible.

9. Mistakes will unavoidably happen. When they do, government must take responsibility, and explain what is being done to mitigate the problem, and how this will ensure that it does not recur.

10. Measures to encourage people not to place additional strain on healthcare resources are vital. Telemedicine, medical hotlines and clear messages about whom to contact before travelling to a healthcare facility will relieve the burden from the “worried well” and reinforce public confidence.

Much more, of course, will be required to contain the spread of Covid-19. The disease will have deep and far-reaching effects on Australia, the region and the global economy. But a more visible public messaging campaign will do much to help Australia ensure that its most critical resource — its people — are a part of the solution. •

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In the last few weeks we have found out that Covid-19, a coronavirus with respiratory symptoms similar to SARS, can transmit before symptoms appear, and can be spread even by those who don’t eventually become sick. Luck, it seems, is against us this time.

A generation ago, infectious diseases were a medical backwater. Polio vaccination had been a stunning success: within a year of its licensing in 1955, the first of twenty-five million doses of the Salk vaccine had been produced by the Commonwealth Serum Laboratories and distributed across Australia. That last dreaded childhood disease was virtually eradicated, at least in countries with highly developed health systems. A combination of isolation and increasingly effective treatment also brought tuberculosis under control, and smallpox was well on the way to eradication: denied a home in its human hosts, it soon disappeared, and not even vaccination was needed any more.

The model seemed set. Virologists would get to work identifying viruses, and vaccines would be developed. Viral diseases dependent on human hosts would be pushed to extinction; bacterial diseases would be treated by antibiotics, increasingly powerful as needed, and intensive infection control.

By the late 1970s, modern medicine seemed to have vanquished the age-old threat of infectious disease. Extending these benefits to poorer countries with weak health systems was the only remaining challenge, but this was a task for do-gooder public health and development types, not the core business of high-prestige cutting-edge medicine.

But then, at the beginning of the 1980s, along came AIDS. Medicine was again faced with a disease it couldn’t cure and a pattern of transmission it didn’t understand. Layered on top of the standard waves of fear and stigma — the overblown fears of contagion and the obsessions with “patient zero” and super-spreaders — were fear and discomfort about its first sufferers, gay men, a new and still contested social category.

It didn’t take long, though, for the standard medical playbook to be deployed. AIDS had come to light in June 1981 when a cluster of unusual diseases among young gay men was reported in the US Centers for Disease Control’s Morbidity and Mortality Weekly Report. Less than three years later, in April 1984, US health and human services secretary Margaret Heckler convened a press conference where, alongside virologist Robert Gallo, she announced that the virus responsible for AIDS had been identified and along with it a blood test to “identify AIDS victims with essentially 100 per cent certainty.”

Heckler went on to assert that a vaccine would be developed within two years. Her confidence was misplaced: last month (on 3 February 2020, to be precise) the latest trial of the not-very-promising-but-most-promising-to-date HIV vaccine candidate was called off because infections in the vaccinated group were no lower than in the control group. The most optimistic forecasts for an effective HIV vaccine have now been pushed out to 2030 at the earliest.

With neither vaccine nor effective treatment available, HIV responses had to turn to social means — exposure avoidance, condom use, clean needles. Aided by various forms of denial and “othering,” HIV gradually developed into a full-blown global pandemic. But the effort to find treatments eventually paid off when it was discovered that antivirals that had been relatively ineffective when used alone could work in combinations of two or three. From 1996, effective HIV treatment was rolled out with an immediate impact on death rates.

The old problem of translating medical solutions to resource-poor settings once again reared its head, but this time a concerted global effort extended access even to the poorest countries within a few years. Antiviral treatment, it emerged, could not only stave off disease but also reduce the infectiousness of those with HIV. And when it was taken by uninfected people as prophylaxis, it could also prevent HIV acquisition. These treatment-driven solutions led to a resurgent triumphalism heralding “the end of AIDS.”

Modern medicine again reckoned itself to have won the fight against infectious disease. But it had only a few years to wait before the next potentially global epidemic appeared on the scene.

By February 2003, three months into the SARS epidemic, local health authorities had reported 305 cases and five deaths from atypical pneumonia of unknown cause. Cases spread to Hong Kong, Vietnam, Canada, Singapore and Taiwan. In March, a coronavirus was identified as the probable cause. By the end of that month, countries were considering travel bans. The World Health Organization started recommending against travel to affected areas, although every travel advisory was resisted by the countries named. Singapore and Hong Kong began imposing quarantine measures and closing schools. China’s response was initially slow, with Guangdong officials defensive, and only once SARS reached Beijing in April 2003 did it become a national priority. Full-scale infection control and quarantine measures were put in place and a national mobilisation launched under vice-premier Wu Yi.

As April turned to May, SARS was more or less under control. The last case found in Vietnam was on 7 April, and the WHO removed Vietnam from the list of affected countries on 28 April. By 5 July the last countries with local chains of transmission, Taiwan and China, were finally declared SARS-free.

China, in particular, learnt from SARS, and thoroughly overhauled its infectious disease control measures. The lack of transparency, reluctance to share information, and conflicts between local and central levels were widely perceived as failings, and China decided to transform itself into a paragon of public health virtue in the face of emerging epidemics by valuing shared information, acting decisively and openly, and cooperating globally.

With new diseases now considered inevitable, a new paradigm focusing on health security began to emerge. Zoonoses were the most likely underlying cause — viruses jumping from animals to humans, with bats the most frequent originating culprit, often with an intermediate animal host. Population pressures, with more and more people crowded into newly expanding urban areas, were meanwhile creating susceptible locations for epidemic outbreak.

The 2013–16 West African Ebola epidemic was confirmation of the new paradigm. Previously, Ebola had emerged only in remote villages and seemed to be self-limiting. Because it was extremely infectious via body fluids, came on rapidly, and had visible symptoms and fatality rates between 50 and 90 per cent, an outbreak could be devastating locally but would burn itself out quickly. The 2013 outbreak was the first time Ebola had spread more extensively, into cities, across national borders and potentially across the globe. This epidemic’s almost 29,000 cases were a hundred times the number in previous Ebola outbreaks.

While international support for the affected West African countries was scandalously slow, it came eventually. The “global public good” of international health solidarity became an accepted norm. Health security was one of the few growth areas in Australia’s international development assistance portfolio under the Abbott–Turnbull government.

Contagion and its results: detail from Black Death At Tournai (1349) by Gilles Le Muisit. Bibliothèque Royale De Belgique

Quarantine, isolation and infection control

When the World Health Organization observed that the tools used successfully against SARS dated largely from the nineteenth century, it could equally have nominated the fourteenth century. Separating sick people from healthy ones had been a response to leprosy since biblical times. But it was not until the plague epidemics of the fourteenth century — the Black Death that swept across Europe and the Middle East — that clear notions of contagion and quarantine began to emerge.

When our descendants look back they are likely to place the intellectual culture of Moorish Al-Andalus among humanity’s high points. One of the outstanding figures of the final period of the Nasrid dynasty in Granada was the scholar and poet Ibn al-Khatib. After the devastating plague that struck the city and many others around the Mediterranean in 1348, he produced a short but keenly observed treatise on the Black Death, Muqni’at al-Sā’il ‘an al-Maraḍ al-Hā’il. Based on empirical observation, it included what is arguably medicine’s first precise account of contagion:

It becomes clear to anyone who has diagnosed or treated the disease that most of the individuals who have had contact with a plague victim will die, whereas the man who has had no exposure will remain healthy. A garment or vessel may carry infection into a house; even an earring can prove fatal to the man who has put it in his ear.

This account of contagion could have been put to good use in implementing effective infection control and quarantine measures at the time, but up until the mid nineteenth century the spread of disease was blamed mainly on vague notions of “miasmas” and putrefied air.

Responses to the Black Death did build on the model of sequestrated leper houses, though, and extended it to population movement in general, developing an elaborate codification of quarantine measures. Maritime cities in particular realised they were vulnerable to ship-borne plague.

In 1377 one of the Adriatic’s main maritime powers, Dubrovnik (known as Ragusa in Latin), introduced a requirement that ships from plague-affected areas be held in isolation for thirty days, and travellers from endemic or epidemic zones for forty days (hence the word quarantine) before they could enter the city. Venice, which had ruled Ragusa until 1358, established similar measures, designating a quarantine station on an island near the Lido in 1423, and other Mediterranean cities followed suit.

Even though Ragusa is credited with being the first to introduce a strict quarantine system, it was not completely successful. An outbreak in 1391 prompted even stricter regulations from 1397, but plague recurred in 1400 and again in 1416. When an outbreak in 1422 turned out to be very small, the measures were reckoned to at last be working.

Another wave of intense plague epidemics across Europe and England came in the mid seventeenth century. By now, elaborate public health apparatuses had been set up to respond with quarantine and isolation measures. Systems were particularly well developed in Italy, and the wealth of documentation that survived was mined brilliantly by Italian economic historian Carlo Cipolla. His fine-grained accounts of how cities like Prato, near Florence, responded to plague are uncanny premonitions of Covid-19 lockdowns in Lombardy today; and the anguish of inhabitants forcibly locked into houses and towns with plague sufferers parallels the experience of passengers and crew of the Diamond Princess.

Plague was not the only disease attracting a quarantine response. Syphilis was the “great pox” of the sixteenth century (as opposed to smallpox — “great” and “small” referring to the size of the pockmarks caused, not the severity of the epidemics). Later, cholera, yellow fever, typhoid and tuberculosis (the “white death”) provoked their own regimes of quarantine and isolation.

From the mid nineteenth century, though, quarantine began to lose its primacy, particularly after John Snow famously identified the contaminated pump handle at the centre of the Broad Street cholera outbreak in London in 1852. An understanding of germs, the precise targeting of infection sources, water purification and other sanitary measures, and the increasing use of vaccination proved effective in battling cholera. Quarantine began to be seen as a blunt, outdated instrument.

The disillusion stemmed partly from a conflation of quarantine, isolation and infection control. Isolation of sick patients and thorough disinfection are designed to definitively interrupt disease transmission. Quarantine seems to hold the same promise, but what needs to be understood is that it is fundamentally about probabilities, not absolutes.

The restriction of population movement by quarantine reduces the chances of exposure to the disease. How much it curbs epidemics depends on two things: how well the quarantine is kept, and the characteristic of the disease pathogen itself.

HIV was not a good candidate for quarantine because its years-long incubation period meant its spread was invariably well under way before it became evident. The cooperation of those who might have been exposed was therefore paramount. Stigma and quarantine are always antagonistic, but that didn’t stop a flurry of reactionary activism in 1992 by Bruce Shepherd, head of the Australian Medical Association, who darkly warned that the “gay lobby” had forced aside sensible public health measures. Shepherd was bouncing off remarks by the almost-sainted Fred Hollows that robust public health measures of identification and isolation of gay men were needed to protect Aboriginal communities from HIV.

A few countries tried to deal with AIDS on the model of tuberculosis sanatoria. But even that measure depended on persuading patients to accept a therapeutic embrace rather than be hunted down. That was Sweden’s initial approach, and that of Cuba when it was dealing with HIV in soldiers returning from supporting African liberation wars — the crucial factor being that these were returning heroes, not marginalised outsiders. Cuba has since gravitated to a more orthodox response, supportive and inclusive of gay men and sex workers. Credit for Cuba’s notably lower HIV rates compared with the rest of its region must also go to its highly effective public health system.

Intense focus: Deborah Birx, US coronavirus response coordinator (centre, left), and vice-president Mike Pence after a meeting on the epidemic with Republican senators yesterday. Andrew Harnik/AP Photo

Getting ahead of an epidemic

The lessons of stigma remain pertinent for Covid-19, although it has already become abundantly clear that it is futile to shun at-risk populations. On the contrary, the circumstances of transmission are all too familiar to all of us.

Particularly worrisome is the fact that transmission can readily occur before any signs of illness appear. Last week the Lancet published an account of one such transmission chain. A young woman passed through Wuhan by train on 21 January on the way to visit her family in Nanjing. There, she stayed with her sisters and mother and went to a family dinner on 23 January, before leaving for another city on 24 January. She had no symptoms until fever and a cough set in on 28 January, and she then tested positive to the coronavirus on 29 January. The immediate family with whom she stayed and three of the relatives at the dinner were subsequently found to be infected; two of the relatives at the dinner went to another family dinner the next day and three of the relatives at the latter dinner were diagnosed with the virus within two weeks.

The circumstances described in the Lancet allow for an unusually precise pinpointing of the timing and chain of transmission. But in every other way the report reveals what could well be happening at tens of thousands of family dinners in at least twenty countries.

“Most cases can still be traced to known contacts or clusters of cases,” the World Health Organization’s director-general, Tedros Adhanom, said at his briefing at the end of last week. “We do not see evidence as yet that the virus is spreading freely in communities. As long as that’s the case, we still have a chance of containing this virus, if robust action is taken to detect cases early, isolate and care for patients, and trace contacts.”

It is a universal rule that public health authorities always try to get ahead of epidemics. It is a near-universal fact that they rarely succeed. Covid-19 is still in the balance: the hopeful sign is that reported cases in China have been in steep decline since the end of January; the less hopeful sign is that significant chains of local transmission have erupted in at least twenty other countries.

New epidemics always seem to provide the opportunity to resurface old prejudices. A case in point is the “anonymous doctor” quoted in a slew of newspapers, including Sydney’s Sunday Telegraph, during the first wave of AIDS hysteria in 1982: “Perhaps we’ve needed a situation like this to demonstrate what we’ve known all along: depravity kills.”

Covid-19’s emergence in China just at a moment when the United States is ramping up its propaganda war against its biggest rival gave partisan commentators the opportunity to make outlandish claims about secrecy, cover-ups and the dire consequence of epidemic outbreak under authoritarian regimes. The reverse may well apply. One reason Covid-19 was identified at all is that public health systems with good disease surveillance are able to pick up unusual disease clusters and peer under the surface. More chaotic systems find it harder.

Once again, AIDS tells the story: the only reason AIDS was identified relatively early was because it affected young gay men who were not expected to be falling ill and dying. It depended on gay men as a category visible to the health system, and it depended on their illness being unusual. In fact, an epidemic of “junkie pneumonia” had been picked up in New York at least two years earlier, but deaths among drug users were not unusual, so no alarm bells rang. Similarly, the spread of AIDS in West Africa, predating the identification of the disease in the United States, disappeared into a background of high mortality.

When a schoolboy with no travel history or contact with known cases was diagnosed with Covid-19 in Washington State last week, his virus was genetically linked to that found in a man, recently returned from Wuhan, who had been identified on 19 January. The evidence points to a silent and untracked spread through the community over at least six weeks. The United States may yet prove one of the biggest challenges to the WHO’s hope of tracking and containing the virus.

Donald Trump’s appointment of vice-president Mike Pence to oversee the coronavirus response has been widely criticised, with many pointing to Pence’s dismal record in responding to a 2015 drug-use-driven HIV outbreak in Indiana when he was governor. In other circumstances, designating a vice-president to lead the response would have been taken as a sign of serious political commitment.

Muting the criticism was the swift and savvy appointment of Deborah Birx to the position of coronavirus response coordinator, reporting to Pence. Birx has been the US global AIDS coordinator since 2014, overseeing a US$7 billion annual budget. Her track record has been in classic public health containment and control, with an intense focus on understanding where the epidemic is, and a ruthless determination to spend available resources on targeted, evidence-based responses.

Buying time

New epidemics inevitably carry the burden of fear, prejudice, conspiracy theories and misinformation. But the brute reality of virus spread can be salutary. It creates an evolutionary pressure towards pragmatically effective responses, and heightens the stakes for the sifting of good information from bad.

The current state of play for Covid-19 suggests that China has been successful in containing the first wave of the epidemic in Wuhan and its surrounding province. The extent of asymptomatic transmission suggests that there may be a larger pool of infections than currently estimated, which means that succeeding waves of infection are likely, but may be smaller. It also means that the spread outside China has been extensive, and long chains of transmission seem inevitable in many, if not most, countries. Restrictions on travel, school closures and the cancelling of big public events will reduce transmission, but the challenge will be in balancing costs against benefits.

One implication of a larger-than-estimated pool of infections is that the case fatality rate may be much lower than the current 3.4 per cent figure. The virus may also weaken, and it may eventually be the case that most people with Covid-19 won’t even notice they have had the disease — much as they don’t notice the common coronaviruses that circulate widely and are at most associated with mild colds. But if anything like the current critical-illness rate of 5 per cent persists, then the burden on health systems will be huge.

One reason quarantine measures are still in place despite the evident breadth of spread is that they buy time. The best use of that time is coordinated global action. It is heartening that journals like the Lancet and publishers including Elsevier have established open-access repositories of the latest information.

The development of treatments and vaccines is also proceeding apace. The 2013–16 Ebola outbreak successfully pioneered vaccine trialling in the middle of an ongoing epidemic. Vaccine efforts ramped up quickly during the 2003 SARS epidemic, though unfortunately those efforts faded as the epidemic receded. This time around, vaccine efforts need to kick in as soon as possible — and be pursued until they reach success.

To the extent that the virus is brought under control it will be because of global cooperation, open and accurate communication, and development of widely accessible “public goods,” in this case vaccines and treatments. It seems like we might still need the “global community” after all. •

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This experiment highlighted what behavioural economists and psychologists know all too well: people are awfully bad at assessing and responding to risk. After 9/11, millions of Americans chose to drive to their destinations rather than fly. The result was more than a thousand extra road fatalities, a tragic yet unsurprising outcome given the probability of dying in a car accident is 5263 times greater than dying from terrorism.

People’s innate inability to assess risks is on display again with the coronavirus. As things currently stand, the probability of catching Covid-19 in Australia is statistically indistinguishable from zero. But not only are people already taking elaborate precautions regardless, the precautions they are taking — wearing the same facemask for hours on end and avoiding Chinese restaurants — range from pointless to ludicrous.

This is a big problem for the economy. The World Bank estimates that 90 per cent of the economic damage from pandemics stems from people’s fear of associating with others. Only 10 per cent comes from the virus itself. The core tenet of macroeconomics — “my spending is your income, and your spending is my income” — encapsulates the problem. The Australian economy is losing $1 billion every month by preventing Chinese tourists from entering the country, to say nothing of the even bigger cost of blocking Chinese students, businesspeople and other visitors.

This brings us to the second big cost of the coronavirus: ineffective and counterproductive policy responses. Too many policymakers are prioritising political expediency over effectiveness. Health experts show that temperature checks at airports are a waste of time. Screening for SARS in Canada in 2003, for example, found zero instances of the disease, despite its killing 774 people, including forty-four in Canada. Yet many policymakers have been quick to implement this measure.

In Laos, the government has put a price ceiling on face masks, fearing that poor people will not be able to afford them. Putting aside the limitations of face masks, the embarrassingly obvious result of this policy is textbook economics: a chronic shortage of face masks.

In China, the government has been busted lying to its citizens, suppressing information and covering up its failures, all of which have made the spread of the virus deadlier.

Australians in China were allowed to come home while Chinese students studying in Australia have been barred, despite both groups carrying the exact same risk. The travel ban on people from China and Iran has similarly not been replicated for Italy, Korea or Japan, despite some of those countries having higher rates of infection. And the government’s claim that hospitals can rely on their “surge capacity” has left many doctors and nurses searching high and low for where this alleged capacity is hidden.

What should the policy response be? Economics has some answers.

Eradicating pandemics is what economists call a “weakest-link public good.” It is a public good because nobody can be excluded from enjoying this benefit, regardless of what country he or she lives in, and one person’s enjoyment of a pandemic-free environment does not stop another person from enjoying the same thing. But it is a weakest-link public good because it depends on the weakest link in the chain. Germany and France can completely eradicate the virus, but if Italy drops the ball, it will be back within days.

Supplying a weakest-link public good requires global cooperation. It requires rich countries with strong healthcare systems to help poor countries with weak healthcare systems. The coronavirus has now emerged in more than sixty countries and has been confirmed in some of the world’s poorest, including those in sub-Saharan Africa. But the bilateral and multilateral cooperation that allowed the world to eradicate smallpox is conspicuously absent. Australia should be helping our neighbours to defeat the virus by sending money, supplies and medical professionals, not randomly blocking some people over others.

Economics is fundamentally about incentives, as is any effective response to the coronavirus. People’s incentives need to be aligned with the social objective. People who don’t have adequate paid sick leave have an incentive to go to work and infect others. People who don’t have medical insurance (many Americans, that is) have an incentive not to seek treatment. And people who feel like they are being abandoned by the system have little incentive to adhere to the system’s quarantines and curfews. If economics shows us anything, it’s that incentives matter.

At the macro level, the economic impact of the coronavirus could be substantial. Friday’s 3.3 per cent fall in the ASX200 is a confronting risk assessment from markets. If the coronavirus is as easy to spread and as dangerous as the 1957 Asian flu, it could kill fourteen million people and wipe $500 billion off global GDP, according to analysis by ANU’s Warwick McKibbin and Alexandra Sidorenko. They find that the cost to Australian GDP could range from 0.80 per cent (the mild scenario) to 2.35 per cent (the moderate scenario), 5.58 per cent (the severe scenario) or 10.58 per cent (the ultra scenario). The severity is driven by how households, firms and governments respond. Given the Australian economy is starting from a weak base, even the mild scenario would halve Australia’s current year-to-year GDP growth (and this is before the weak March quarter is considered).

The Morrison government is getting ahead of the curve by announcing a willingness to implement “targeted, modest and scalable” fiscal stimulus. The Reserve Bank has similarly expressed concern, although its forecast of a 0.2 per cent hit to GDP growth in early February now seems optimistic. If the US Federal Reserve cuts interest rates, which markets are pricing at a 90 per cent probability, the Aussie dollar will appreciate, putting more pressure on our Reserve Bank to cut rates and move closer to quantitative easing. Markets are putting the chances of a rate cut from the RBA at 18 per cent for March and 68 per cent for April.

The problem is that macroeconomic stimulus — whether it’s fiscal stimulus or monetary stimulus — works well for demand-side shocks (where consumers stop spending) but less well for supply-side shocks (where business supply chains, investment and production come under pressure). The coronavirus is both, but the supply-side impacts of the virus mean that the benefits of stimulus will be more limited. Increased consumer demand is of limited value when firms can’t access their supply chains. This means that governments must be proactive in keeping markets open and helping businesses weather the storm.

The ultimate economic cost of the coronavirus is unknown. But what we do know is that the bulk of the cost will come from how consumers and governments respond, underscoring the importance of a measured, science-based approach. If panic and political expediency are prioritised over policy effectiveness, the treatment will be worse than the disease. •

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The fact that the government was able to misuse these two programs so easily raises questions about other health-related funding decisions.

Health spending ranges from targeted, small-scale grants to multibillion-dollar national programs. Over the past two weeks alone, health minister Greg Hunt has made six significant funding announcements, including $22.3 million for “new treatments and breakthrough cures,” $5.5 million for ten new medical research projects, $32 million for partnerships between industry and researchers, an unspecified amount for additions to the list of subsidised pharmaceuticals, and the provision of free glucose monitoring devices for 21,000 people with diabetes (as part of a broader $300 million program). Two weeks earlier the prime minister had announced $76 million in new funding to support the mental health needs of people affected by the bushfires, including grants targeting affected communities.

Given what we know about the sports rorts controversy, can we be confident that these decisions were made without reference to political advantage? After all, Senator McKenzie is not the first politician to be accused of pork-barrelling: previous federal governments have come under scrutiny for issuing additional MRI licences in marginal electorates, for example, or, more famously, promising funds to keep Tasmania’s Mersey Hospital open despite expert advice to the contrary.

Funding decisions targeted at marginal seats are easy to spot. But politics has triumphed over policy in many other cases, including in some of the largest healthcare programs. They go unnoticed partly because of the size and complexity of the programs, which makes it difficult to identify when and why crucial decisions are made. But the lack of recognition also shows how the disproportionate influence of interest groups is seen as a routine component of policy development rather than an intentional strategy to advance certain interests over those of Australian consumers.

Take, for example, one of Australia’s biggest health programs, the Pharmaceutical Benefits Scheme, or PBS. Considering the scheme represents around 15 per cent of the health budget, or just under $13 billion in 2019–20, it’s reassuring to know that decisions about which medicines to subsidise are based on expert advice from the Pharmaceutical Benefits Advisory Committee, or PBAC, and subcommittees made up of clinicians, health economists, consumers and other stakeholders.

There’s a problem, though. The committee might be independent, but it is purely advisory. Final decisions are made by the health minister or (if the medicine is likely to cost more than $20 million a year) federal cabinet.

This discretion provides a window of opportunity for companies and professional groups that want to influence listing and pricing decisions. It’s hard to say how often they succeed, but we do know that (at the very least) pharmaceutical companies invest substantial resources in attempting to influence PBS decisions, in many cases funding consumer organisations and “experts” to advocate on their behalf. The evidence that drug prices on the PBS are higher overall than in comparable countries suggests that this investment might be paying off.

Can the politicisation of the PBS be reduced? Lobbying in general, including by pharmaceutical companies, could be made more transparent by applying the same standards to all people seeking to influence government, whether they are “in house” (which currently exempts them from the lobbying register) or external. The drug testing that companies plan to use in applications for PBS listing could be pre-registered to strengthen the evidence base for decisions. More effective procurement mechanisms for medicines — competitive tendering, for example, as in New Zealand — could be adopted. And local prices could be benchmarked against international prices.

Each of these safeguards has already been proposed without success. Increasing the transparency and objectivity of the PBS process can be difficult when both government and the pharmaceutical sector benefit from its politicisation — pharmaceutical companies because they can use their influence to have their products listed or their prices raised, governments because listing new medicines provides a steady stream of positive media opportunities.

Medicare is another major area of health spending (around $23 billion in 2018–19) in which the evidence suggests political interests influence funding decisions. The implementation of recommendations of the MBS Review Taskforce is a good example. The taskforce was established after health economist Adam Elshaug and his colleagues identified more than 150 potentially low-value procedures on the Medicare Benefits Schedule, or MBS. Among them were knee arthroscopies and spinal fusions (in specific circumstances) that carried significant risks for patients and were backed by little or no evidence.

Of the almost 6000 items on the MBS, Elshaug found, only around 3 per cent had been formally assessed against contemporary evidence of safety, effectiveness and cost-effectiveness. Many of these items were listed some time ago and, until recently, there had been no systematic process for updating listings in line with new research and changes in clinical practice.

Despite the fact that the taskforce’s seventy committees have made extensive recommendations in sixty-seven reports since work began in 2015, the number of low-value procedures on the schedule has not fallen significantly.

Not surprisingly, medical groups have lobbied hard. Anaesthetists, for example, objected to changes that would have reduced rebates for their services in line with evidence that the current arrangements don’t represent good value. GPs objected when one of the review committees recommended more Medicare funding for nurse practitioner services. Clinical psychologists objected to a proposal to remove the differential rebates between services provided by clinical and non-clinical psychologists.

The government has been reluctant to risk political damage from conflict with the medical profession, particularly since the health minister has worked hard to re-establish the Coalition’s credibility in his portfolio after Labor’s 2016 “Mediscare” campaign and public relations mistakes by previous ministers.

Medical groups know that the Coalition can’t afford a public battle, and they have used this fact to their advantage by lobbying against changes that might reduce the earning potential of some of their members. As a result, much low-value care continues to be funded through Medicare and consumers continue to receive treatment that exposes them to risk but delivers little or no benefit.

As is the case with PBS listings, identifying the exact processes of influence is difficult. Given the fate of many of the MBS Review Taskforce’s recommendations, though, it appears that interest groups have been successful in persuading the government to let political considerations override the benefits of making evidence-based changes.

One of the most politicised areas of health funding is the private health insurance rebate, a scheme that costs taxpayers around $6 billion in direct subsidies and a further $6 billion mainly in revenue lost via tax breaks for higher earners. This adds up to around 120 times the funding that went into the controversial Community Sports Infrastructure Program grants and yet, despite frequent calls for a review, the scheme has never been evaluated against its aims.

The private insurance rebate is an example of how an ostensibly universal program can have a different impact on different communities, depending on their political colour. Because membership of private funds varies significantly across regions, the allocation of funding under this scheme differs according to a community’s political affiliation.

Put simply, Coalition voters are much more likely to take out private health insurance than people who support Labor or the Greens. In fact, the market research company Roy Morgan found in 2016 that twenty-one out of the twenty-five electorates with the highest level of private health insurance membership were Coalition-held.

Four years on, this situation has barely changed — although two of the Coalition seats have changed hands, one to an independent (Warringah) and one to Labor (Hindmarsh). Even so, the ten electorates with the highest level of private health insurance membership are all still Coalition seats and, overall, three-quarters of the top twenty-five electorates are represented by Coalition MPs.

This means that the private health rebate goes disproportionately to areas represented by Coalition members. While all taxpayers contribute to the subsidies via their taxes, areas with a greater proportion of Coalition voters receive significantly more benefits. Without any overt political agenda, the rebate can therefore be a highly effective way of directing public funding into areas with a specific political allegiance.

A much more equitable use of this funding would be to redirect the $12 billion towards services — public hospitals, public dental services and allied health services — that benefit the whole community. This would also be a much more efficient use of resources.

Yet another big spending area within the health portfolio is the Community Pharmacy Agreement, or CPA, a deal between the federal government and the Pharmacy Guild that sets remuneration levels for the dispensing of medicines and funds home medicine reviews and other pharmacy-related programs. The current PGA, the sixth, includes around $19 billion of funding over five years; the next one (currently being developed) is reported to include around $25 billion.

The potential for improper influence in the CPA largely comes from the lack of transparency in its development and execution. Negotiations involve only limited input from consumers, other peak pharmacy groups and other key stakeholders, obscuring whether the agreement’s remuneration levels represent good value for the Australian community and whether all the conditions outlined in the agreement have been met.

The Australian National Audit Office shares these concerns. In its report on the administration of the Fifth Community Pharmacy Agreement, it found that

shortcomings in Health’s performance reporting and 5CPA [Fifth Community Pharmacy Agreement] evaluation framework mean that the department is not well positioned to assess whether the Commonwealth is receiving value for money from the agreement overall, or performance against its six principles and objectives…

and

there is no ready basis for the Parliament or other stakeholders to determine the actual cost of pharmacy remuneration delivered under the 5CPA.

In this environment, the Pharmacy Guild can promote its own interests at the expense of the community. Extensive evidence suggests this has occurred over a series of CPAs, resulting in anti-competitive practices, higher prices and reduced access for consumers.

Unlike in the case of the sports rorts affair, though, the findings of the auditor-general (and other similar reviews and inquiries) have resulted in very little negative publicity for the responsible minister or the government. In fact, Greg Hunt is currently negotiating a seventh CPA with the Pharmacy Guild that will lock in another multibillion-dollar agreement for the next five years.

Of course, interest groups can only exert power over governments to the extent that governments allow themselves to be influenced. A crucial enabling factor in all of these examples is the willingness of governments of all persuasions to trade off good policy outcomes for short-term political gains, even when independent, evidence-based processes are in place (the PBS), or the evidence suggests that funding mechanisms and processes serve the interests of specific groups at the expense of the general community (the PGA).

The problem could be at least partly solved by reducing the government’s role in health funding decisions, while still allowing it to set broad policy directions and respond to emerging health threats. This could be done in a number of ways.

First, a new independent body could take on many of the decisions currently made by government. Labor’s pre-election proposal for an independent body to administer health funding is worth considering, although it would need to be given final responsibility for at least some health funding decisions and not just function in an advisory capacity.

Second, mechanisms for giving consumers input into health resource allocation decisions should be used throughout the health system. A number of existing models, such as citizens’ juries, have been used successfully in Australia for this purpose. They can tackle inequities in our current system by bringing in groups usually under-represented in health decision-making, including Aboriginal and Torres Strait Islanders, people with chronic and complex conditions, people with lived experience of mental illness and people from rural areas.

Third, Primary Healthcare Networks, Aboriginal Medical Centres and other community-based health organisations could be given a greater role in resource allocation. These organisations have transparent governance processes and consumer/community representation, and are far removed from the day-to-day pressures of federal politics. They also know their communities’ needs far better than ministers and bureaucrats in Canberra. Both Britain and New Zealand have decentralised significant components of health funding and offer important lessons for Australia.

Any of these options would help depoliticise the health system and reduce the influence of a small number of interest groups. They could also tackle the perennial underfunding of preventive health measures and take account of the social determinants of health and the health impacts of climate change.

Even with these changes, though, governments could continue to make health policy and funding decisions that deliver political benefits at the expense of the wider community. Given that both sides of politics have a vested interest in maintaining the status quo, supporting free and independent reporting on healthcare decision-making should also be a high priority. •

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The danger for Wuhan is that it will come to be known simply as the virus city. While Covid-19 has somewhat offensively been referred to internationally as the “China virus” or “Chinese virus,” in China it is popularly known as the Wuhan virus, or Wuhan pneumonia. The year of the rat, complain Wuhanese, has left them feeling like the “rats crossing the road” (guojie laoshu). Other Chinese are avoiding them like the plague.

It doesn’t take an epidemic to bring out regional prejudices in China. Wuhan’s detractors — and there are quite a few of them — regard it as a dirty and unattractive place where people swear a lot. Spend a bit of time in Hangzhou, says one émigré, and you’ll realise that the educational level in Wuhan is rather low. Not so, say the city’s champions. People in Wuhan might be a bit rough and ready, but they are open to the outside world, adaptable, tolerant and resilient.

Like jokes about the Englishman, the Scot and the Irishman, there are variations for virtually every other place in China. But the virus has given a nasty edge to criticism of the Wuhanese. One person jokes about throwing out his “Wuhan duck necks,” a local delicacy, and another about giving up his recently acquired Wuhan girlfriend. Wuhan novelist Ai Jingjing, plainly affronted by the charge that the city’s eating habits caused the outbreak, felt impelled to go online to explain to the rest of China what people in Wuhan actually do like to eat: fish, rice and lotus root.

Along with the jokes and abuse has come ostracism. On 27 January, sixteen people from Wuhan narrowly avoided being stranded in Japan after seventy Shanghainese refused to travel on the same plane. “Are we compatriots or what?” asked a furious victim. It took the intervention of consular staff to end the stand-off.

Wuhan isn’t like Beijing or Shanghai. Despite its size, its pivotal position in central China and its many universities, it doesn’t have an identifiable reputation that might help it overcome negative associations. This is partly because its rich history, the natural source of cultural standing, is split among its component parts: Wuchang, Hanyang and Hankou. Divided from each other by the Yangtze and Han rivers, these were formerly distinct cities, and local identity is still marked. “I’m from Hankou,” says a Wuhan student to a visitor. “I’ve just come to Wuchang to attend university.”

As a great port and market town for centuries, Hankou, or Hankow in an older spelling, is the most recognisable of the three place names. Neighbouring Hanyang, once the seat of government for Hankou, is now the poor cousin. Across the Yangtze River, Wuchang, long the provincial capital of Hubei and its cultural centre, has great historical significance. It was the Wuchang Uprising of 1911 that sparked the revolution that led to the founding of the Republic of China, Asia’s first republic, in 1912.

Wuhan’s constituent settlements — Hankow (now known as Hankou), Hanyang and Wuchang — probably in the 1920s. From the 1924 edition of the Japanese Government Railways Guide to China. Antiqua Print Gallery/Alamy

This history could have been leveraged to greater advantage for Wuhan as a whole, but China’s ruling Communist Party prefers history to be about another revolution — the one that culminated in the People’s Republic of China in 1949. Wuchang does have a museum to the 1911 revolution, but the story of that first republic is tightly controlled on the mainland. For an insight as to why, you need only look at Taiwan, a largely unrecognised state that is steadily resisting incorporation into the People’s Republic and still formally bears the title of “Republic of China.”

A rather rocky administrative history brought Wuchang, Hanyang and Hankou together as Wuhan under the Nationalists in the 1920s, and then again under the Communists. The histories connected with the name of this larger entity are also difficult ones. In 1927 Wuhan was the site of a purge of communists from the left-wing government formed in the city during the Nationalist Revolution. In 1967, during the Cultural Revolution, it was the site of armed conflict that left more a thousand dead. That clash — the Wuhan Incident, as it came to be known — was condemned at the time as counterrevolutionary, but when the verdict was reversed after Mao’s death it didn’t do much for a subdued Wuhan. Like much of the Cultural Revolution, the Wuhan Incident is passed over in silence, or at best smoothed over.

These histories of violent struggle are somehow consistent with the popular characterisation of Wuhanese as fierce and aggressive. But Wuhan has had its place in the sun, and in a less controlled ideological environment that would be celebrated. Between January and October 1938, following the infamous siege of Nanjing by the Japanese, Wuhan served as the refuge for the Nationalist government and became the provisional capital of China. In these months, writes historian Stephen MacKinnon, “the metropolis blossomed.” Crowded with refugees, on tenterhooks about the Japanese advance, the city came into its own.

“To a degree unmatched in any Chinese capital before or since,” writes McKinnon, “Wuhan enjoyed parliamentary style debate and political experimentation, the flowering of a free press, and the unleashing and redirection of enormous creative energies in cultural spheres.”

MacKinnon’s book, Wuhan, 1938: War, Refugees, and the Making of Modern China (Berkeley, 2008), has been translated into Chinese and published by Wuhan Press. As the present epidemic runs its course, Wuhan people might care to read it, and remember the ten months when their city symbolised to the entire country unity and courage in the face of apparently insuperable odds. •

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