When I started this post on 17 July I wrote:
Much of the last week the debate has raged as to whether our aim in tackling COVID-19 should be suppression or elimination. The debate has involved short memories, the loose use of language, and a false binary. Also the notion that every country should use the same strategy.
PM Scott Morrison will tell you that ‘aggressive suppression’ is the way to go, and that ‘elimination’ would break the economy. He also said that we need a few people getting sick and dying to keep our minds on the job.
Scotty from Marketing did not say it quite that way, but that is what he meant.
On 15 July Katharine Murphy wrote Scott Morrison says Australia cannot shut down to contain second wave of Covid-19.
At that point Morrison was not against Victoria’s imposition of Stage 3 restrictions, and warned that a lack of vigilance could readily lead to scenes like we saw in New York:
Morrison said lockdowns were necessary in Victoria given the significant spike in infections in the state, but “your protection against the virus is not shutting things down all the time”.
“You have to do that sometimes, as is the case in Victoria,” he said. He said trying to eliminate the virus wasn’t the “right strategy” for Australia.
- “You don’t just shut the whole country down because that is not sustainable. I’ve heard that argument. You’d be doubling unemployment potentially, and even worse.”
Morrison said it was impossible to achieve elimination “unless we are not going to allow any freight, or medical supplies into Australia, or any exports into Australia, or things like this – there is always going to be a connection between Australia and the rest of the world”.
No-one was talking about shutting down Australia. They were, however, pointing out that New Zealand had shut down quickly, and was reaping the economic reward of ‘snap-back’ at that time. At that time the Crossroads Hotel outbreak had just occurred. Morrison said:
- the responses by governments to the threat achieved the correct balance between suppression of the virus and allowing economic activity. Morrison said governments had to keep “tension in the cord” and he praised the efforts under way in New South Wales to contain a smaller outbreak in the state.
However, the problem was that apart from saying that all states should be like New South Wales there was never any precision about what ‘aggressive suppression’ meant. In spite of superficial agreement in the newly formed National Cabinet states clearly had their own views, not always clearly defined either, and confused by talk of ‘hotspots’, which could refer to anything from a cluster based on a hotel to a whole state.
In mid-July, Queensland was open to NSW, Victoria was in Stage 3 lockdown, and the Sydney Crossroads Hotel cluster had emerged, which was to generate a series of other clusters, so in quick succession, Queensland experienced the Logan infection, brought from Melbourne by two young women, and then Premier Palaszczuk, acting on advice from her Chief health Officer, declared Sydney a hotspot and closed the NSW border.
There is nothing wrong as such in what Morrison said in the link above, but he has failed, I think, on three counts.
Firstly, there has never been a clearly articulated national statement of what our COVID-19 target is. Given that health is a state responsibility, a nationally coherent approach always needed consensus, that is, the agreement of each participant to a concrete and clearly articulated goal, not some vaguely articulated aim.
Secondly, he has not understood his constitutional role, which in a federation was through leadership to get all the states on the same page, and then provide help and support.
By contrast, in a BBC report I heard, that is exactly what Angela Merkel has done in Germany in a similar federal system with 16 states and cities.
Morrison has provided a public running commentary on what he likes and dislikes, and in some cases has tried to direct.
Thirdly, he has played politics. Anthony Albanese has said that Morrison likes to take credit for anything good that happens with the coronavirus, and blame the states for anything bad. He has also clearly given his senior ministers a licence to attack the Labor states, as Josh Frydenberg has done repeatedly with Dan Andrews and most recently by piling into Qld Deputy Premier Steven Miles calling him “a stumbling, bumbling lightweight that no one’s ever heard of”.
Here I need to point out that in Queensland the Chief Health Officer’s responsibility for making directions in a health emergency was legislated under the Public Health Act 2005 (Qld), before Annastacia Palaszczuk entered parliament. Had she legislated to take back those powers, or ignored them, she would have been attacked for being power hungry by the LNP opposition.
The current occupant, Dr Jeanette Young, was appointed in 2005, and has now worked with four premiers on six pandemics. Palaszczuk, Young and Miles may not always get it right, but they work as a team.
I can’t find the link, but Raina MacIntyre explained the confusion of terminolgy very clearly to Norman Swan on ABC RN. From my notes she said that through the WHO the world had agreed definitions of these terms.
‘Elimination’ meant that you had cleared the virus from your country and had every expectation that it would not return in the future, usually through immunisation, and had the public health measures in place so that if it were to appear it would be quickly dealt with. Then you can apply for a certification, which I expect would be judged by a WHO panel.
MacIntyre says that, given the infectiousness of this virus, together with its ability to infect when pre- or asymptomatic, no country could ever make that claim, unless it isolated itself from all physical human contact through strict quarantine measures.
No country can do that in the longer foreseeable term, she says.
‘Eradication’ is not something any one country can do. That term only applies when all countries have eliminated it, and it survives nowhere in the wild.
MacIntyre says that the New Zealand example is irrelevant. Yes, like Australia, it is girt by sea, but no-one much goes there, or at least needs to go there. Within NZ the population is spread out, apart from Auckland (ca 1.6m). She said that New Zealand in COVID terms, was simply not comparable to Sydney and Melbourne.
She did not spell this out, but this virus loves big cities and dense populations.
New Zealand with around 4.9m people is less populous than Queensland, Melbourne or Sydney.
So on the same grounds I’m sure MacIntyre is not impressed with arguments based on the success of WA, SA, Tasmania and the Territories. She did not address Queensland directly (more of Qld later) but the point is that Sydney and Melbourne are in a different league.
The next main point made by MacIntyre is that the differences in practice between ‘aggressive suppression’ and ‘elimination’ are small – a matter of a tweak here and there, and the time period various measures are applied. Both can involve lockdowns, but living with the virus sans a vaccine is much the same under both regimes.
On July 16 The Conversation published a fine article by Anita Heywood, Associate Professor, UNSW and C Raina MacIntyre, Professor of Global Biosecurity, NHMRC Principal Research Fellow, Head, Biosecurity Program, Kirby Institute, UNSW entitled Eradication, elimination, suppression: let’s understand what they mean before debating Australia’s course.
They draw on the recognised international terminology published here by the CDC:
- Control: The reduction of disease incidence, prevalence, morbidity or mortality to a locally acceptable level as a result of deliberate efforts; continued intervention measures are required to maintain the reduction. Example: diarrhoeal diseases.
- Elimination of disease: Reduction to zero of the incidence of a specified disease in a defined geographical area as a result of deliberate efforts; continued intervention measures are required. Example: neonatal tetanus.
- Elimination of infections: Reduction to zero of the incidence of infection caused by a specific agent in a defined geographical area as a result of deliberate efforts; continued measures to prevent re-establishment of transmission are required. Example: measles, poliomyelitis.
- Eradication: Permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed. Example: smallpox.
- Extinction: The specific infectious agent no longer exists in nature or in the laboratory. Example: none.
Heywood and MacIntyre say that in practice:
Elimination and suppression strategies employ the same control measures. For COVID-19, these include:
- rapid identification and isolation of cases
- timely and comprehensive contact tracing
- testing and quarantining of contacts
- varying degrees of social distancing (lockdown, banning mass gatherings, keeping 1.5m distance from others)
- border controls: restricting entry through travel bans, and quarantine of returning international travellers
- face masks to reduce transmission.
The differences between a suppression strategy and an elimination strategy are the strictness, timing, and duration with which these measures are applied, especially travel restrictions.
For example, under a suppression strategy, physical distancing requirements might be lifted while there’s still a low level of community transmission. But under an elimination strategy, these measures would remain in place until there’s no detectable community transmission.
In those terms Victoria is pursuing an elimination strategy which as Tim Colebatch points out in Covid-10: where next? (shouldn’t that be Covid-19?) no country has met. Queensland has said they want to see two successive transmission periods, that is 28 days, without community transmission. That means you don’t count returnees from overseas in quarantine, or anyone already identified as a contact and in isolation.
In NSW we find that advice from Chief Health Officer to schools assures schools that:
- These updated measures will assist us to achieve the NSW Government’s aim of eliminating community transmission in NSW…
To state Qld’s goal another way, they want no new cases popping up in the community that are not already under control for 28 days. Such cases are becoming rare in NSW. I think Qld and NSW goals are not so different and could be achieved before Christmas.
In order to get there, however, it is not helpful for the PM and the NSW premier to simply demand that Qld health authorities perform to the NSW standard.
If that is too strict, we might look at Taiwan, where with a population of 23.8 million it has had only two days with more than five infections since 20 April, with a maximum of seven.
Morrison has said that we need to live with the virus. Indeed we do, the question is at what level?
I have compared our 7-day running average of new cases with other countries we might learn from, making the adjustment to reflect their level of infection in terms of our population.
Elmer Funke Kupper in Infections are just the new normal published on 6 July put a very rational case for opening our internal borders and living with infection rates of 100-200 per day, comparing us with Germany, which at that time had a 7-day average in our terms of around 80. Our average back then was 109. This is what happened here:
We were at 109 per day back then, rising fast, peaking at 552, and are now down to 19.
This is Germany:
In early July they were about 117 per day in our terms, but are now in a disturbing uptrend now at 554, which is about 7 times where they were at their lowest point in early June.
Kupper was going to lock away our older folk, and was taking a very rational view across the spectrum to derive net deaths from all causes including influenza and suicide.
Germany has the advantage of having fewer large cities than we have, and an apparently a strong health system, but suffers from porous borders in the Shengen Area, and hard winters, where the virus thrives especially as activity moves indoors.
Health decisions will never be made entirely on rational grounds. If they were we should consider emulating China, which has been hugely successful in extinguishing outbreaks and keeping infections low. Europe in general is entering a new crisis period, especially in places like France and the UK, where the new case loads are 4,630 and 2089 per day respectively in our terms, and climbing fast.
Europe and the US provide patterns of infection that we would regard as failure. We need to find our own solutions in our own circumstances, being as rational and scientific as possible, but also within a social setting with its own characteristics.
In Australia we have two large cities and high urbanisation generally. Apart from state capitals we have two hub cities, Canberra and The Gold Coast, which create transmission pathways from everywhere to everywhere.
We also have more casualised labor than most comparable countries, with no sick leave, especially in the health and aged care systems, which are especially vulnerable to the virus. Our institutional aged care system is in fact scandalously neglected. This image from a Raina MacIntyre lecture illustrates the problem from Victoria’s experience:
MacIntyre points out also that we are simply not up to speed in using masks as a frontline tool for the public, or in our health system. On occupational PPE she posts this image, which contrasts health workers with cleaners about to disinfect a gym where there was one infected case:
A further factor is population compliance. MacIntyre points out that masks tend to be made compulsory in public settings only when there has been a lockdown. Mask-wearing increased noticeably in Brisbane when we had the recent scare, but now is becoming rare again. If they were made compulsory now with so little virus around, I doubt there would be high compliance.
Generally, though, according to a QU academic who studies the issue, Australians are 80 to 90% compliant to restrictions. He contrasted this with the English, who he said were only 20% compliant.
So enforcement is also an issue, one where China provides an example we would not follow.
I’m inclined to think that public expectation together with economic necessity will prize borders open by Christmas. South Australia’s recent opening, I would hazard a guess, was in part motivated by a 90% reduction in tourist activity, and the need to co-operate with NSW and Victoria in fruit harvesting. WA is currently looking at a shortage of 1,000 workers, many requiring heavy machinery licenses, to harvest and move their grain crop. The Courier Mail reports that backpacker availability to work on farms is expected to reduce from 220,000 to 20,000 next year.
As to opening up internationally, Tim Colebatch’s article says:
The idea of setting up a travel bubble among relatively Covid-free countries within our region ought to be a winner. While new case numbers are exploding in Indonesia (4634 yesterday), the Philippines (2180) and Nepal (1497), much of Asia is reporting little new activity. Last week, for example, the growth in the total caseload per million people was zero in China, Taiwan, Vietnam and Papua New Guinea, one in Japan, two in Australia, four in New Zealand and the Maldives, and five in Sri Lanka. Most of the South Pacific remains Covid-free. Why not open the doors to safe neighbours?
Unfortunately, there are lots of reasons why. It might happen with New Zealand, maybe the South Pacific, possibly even Japan. But there are obvious political problems for Australia in negotiating an opening with China in this environment. And if we don’t open up to China — or it refuses to open to us — we risk another Beijing tantrum if we open up to Taiwan.
In other countries, the data can’t be trusted…
New Zealand, China and Taiwan are the cleanest prospects. South Korea and Japan have new case loads of 44 and 87 per day in our terms, with the trends in the right direction. Vietnam and Thailand may also be worth consideration.
Looking forward to vaccine, Raina MacIntyre says that the promised efficacy of 50% will fall short of herd immunity which requires at least 70%. A survey reported in the CM says that 80% of Australians are willing to be vaccinated. This article which identifies Byron Bay as the anti-vaxxer capital of Australia suggests that 91 to 95% will be required.
MacIntyre says that cures are being widely researched, but so far there are none. The importance of cures in disease control is exemplified by diarrhoea.
Control of this virus is going to require continual effort and readiness for the foreseeable future.
Here are some links I gathered but didn’t use:
Bill Bowtell Copy New Zealand or risk repeated Australian lockdowns: Bill Bowtell
Rick Morton – How the second wave broke