COVID-19 ROAD TO RECOVERY — WHAT GOVERNMENTS CAN LEARN FROM EACH OTHER: Policymakers are now trying to work out what we should be aiming for — total elimination of the virus, or merely keeping it under control until a vaccine is available. David Donaldson spoke with several scholars for their take on the matter.
With Australia registering below 50 new COVID-19 cases a day — down from around 460 on the worst day — thoughts are turning to loosening lockdown restrictions.
Prime Minister Scott Morrison said on Thursday the National Cabinet is considering the “road to recovery” — but signalled restrictions will remain for at least the next month.
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Australia is not alone in wanting to restart life. In recent days in China, where the outbreak started much sooner, many people have finally been able to leave their apartments for the first time in months.
Norway, which is at a similar point on the infection curve to Australia, is about to start the slow process of opening back up. From April 20, Norwegian kindergartens will restart and the ban on staying in holiday houses will be lifted, with other changes to follow. Czechia, Austria, Denmark and Spain are all easing restrictions — though the nature of lockdowns (and the epidemic) is different in each country.
Morrison has highlighted the need to strengthen three capabilities ahead of reopening in Australia: a more extensive testing regime, better tracing, and the ability to respond swiftly to local outbreaks.
But there are many other questions that will need to be considered in the process.
Policymakers are now trying to work out what we should be aiming for — total elimination of the virus, or merely keeping it under control until a vaccine is available.
Responses in the first part of the suppression phase have been shaped by three main strategies: the hands-off, or “herd immunity” approach, where government does little to slow the outbreak; slowing the spread to make it more manageable, so hospitals are not overwhelmed; and slowing the spread far enough that case numbers fall — if each infected person passes the coronavirus on to fewer than one other, numbers will shrink.
Modelling released a month ago suggested the more government restricts movement and social contact, the more people can be saved from infection. Experience since then has shown countries that implemented lockdowns quickly have suffered far less than even those that waited a week or two longer.
But the success of lockdowns in countries like Australia and New Zealand has raised the prospect of a new goal: elimination. The Grattan Institute’s John Daley and Stephen Duckett argue Australia should aim to eliminate the virus. If successful, this would allow life to return to something like normal domestically — provided international travel stays off the menu for the next couple of years (except maybe to New Zealand).
And if Australia fails to get to zero, we’ll still be close, making any outbreaks easier to contain.
La Trobe University’s Dr Joel Miller, who uses mathematical models to guide infectious disease policy, says this approach makes sense.
“I think an attempt to eliminate the disease in Australia is the right thing to do,” he tells The Mandarin.
“Numbers are low enough that it’s plausible and right now is the time to try.”
But hospitals and public health infrastructure should prepare for that effort to fail.
“Even if we do fail, we are in the meantime getting other benefits from the effort,” says Miller.
“In the push to control the disease, public health workers would gain more experience with contact tracing. The time gained by that push would mean hospitals are able to get more resources in place. Our testing capacity would increase. We may learn better treatments so that those who become sick can receive better care. The skill of contact tracers and the capacity for tests will play a large role in our ability to keep infection numbers low for long periods.”
If elimination efforts don’t work, we’ll need to go through stages of loosening and tightening restrictions again.
“Hopefully we are able to keep growth slow so that the less restrictive stages can last for a while. This may result in asynchronous outbreaks in different regions, so we may see more regional variation in policies and I would expect restrictions on domestic travel are likely to remain.”
The over-riding goal should be to “attempt to keep infections low until a vaccine is available or we have very effective treatments”, says Miller.
But be careful
There are “a lot of unknowns” still, cautions Hassan Vally, associate professor of public health at La Trobe.
“What is really clear is that we are nowhere near the end of this epidemic in Australia.”
The country is starting to gain control over cases coming from overseas and transmission chains from cruise ships, but now we should “cast our eyes towards what’s happening in terms of community transmission”, he tells The Mandarin.
Testing strategies have mainly focused on travellers and big, known sources like cruise ships until recently, so recent changes to testing criteria will allow authorities to look harder for any possible unrecorded community outbreaks.
“We don’t actually know a whole lot about community transmission. We certainly know it’s occurring, and we’ve detected quite a bit of it, but we don’t know if the real level of community transmission is twice as high as we’re detecting, five times as high, 10 times as high. We just don’t know.”
Vally also notes that elimination is a big ask.
“In effect you have to detect every case, and you have to interrupt the chain of transmission for every case until obviously you have no cases at all in the country.”
This would require even more stringent lockdown measures, he thinks — and Australia’s openness to the rest of the world would make it difficult to maintain zero cases.
“Elimination is a very big challenge for a place like Australia.
“I think that’s why the government has made it very clear they’re pursuing a policy of suppression of the spread of the virus, which means you can have slightly less stringent lockdown measures, and as long as you flatten the curve and make sure the load on the health system is manageable, that’s one path through the epidemic in Australia.”
The Australian people and the government have done a good job so far, says Vally — but there’s still plenty of work to go.
We should continue monitoring over the next month, and if things are going well, we can then ease restrictions “in a controlled way”, he argues.
“This is the period where the temptation is to ease up thinking we’ve done the job, and we haven’t. We’ve got to hang in there.”
UNSW Adjunct Professor Bill Bowtell “believes strongly” in elimination. He doesn’t think we are yet on the path to achieving it — though New Zealand seems to be.
“There has to be an expanded testing regime, and there has to be a range of things, like perhaps technology apps for contact tracing, the use of masks, and a very clear understanding on the part of the Australian people that if anything goes wrong, it’ll go back harder and faster than it was before.”
He cautions against thinking we’re close to the end yet.
“We have to deal with this thing as it is, and not look for the easy answers that just don’t exist. It’ll be a long, slow grind getting health arrangements right, and it’ll be even longer and slower dealing with the economic and social cataclysm that’s overwhelmed us.”
Bowtell is also disappointed at the amount of secrecy around official decision making on COVID-19. He thinks a lack of external expert input and debate may have contributed to early mistakes around closing borders, cruise ships, and equipment stockpiling.
He compared it to the more transparent approach to tackling HIV in the 1980s, with which he was involved.
“Everything then was upfront and open, there was a robust debate, and we came up with a radical and bold and workable set of measures that really were pretty much the best in the world.”
If the virus turns out to be much harder to control — for example if a vaccine cannot be found — the problem becomes harder.
Some advocate a ‘herd immunity’ approach. Former NSW minister Pru Goward has suggested that if it proves impossible to develop a vaccine, we should consider isolating the old and vulnerable, and gradually let people at low risk of dying become infected to build up a significant level of population immunity and protect against future outbreaks.
Modelling of the British and American systems suggests even this approach could lead to overwhelmed intensive care units — though how it develops would depend on how restrictions were phased out.
Disease modeller Joel Miller highlights three major problems with Goward’s idea:
- Even under optimistic scenarios, the number of people who would need to be infected is very large — well over 50%. “It is not clear to me that there are enough low-risk individuals in Australia to meet that level,” he says. This becomes impractical if, for example, you only allow infection in those who don’t live in the same household as someone at high risk.
- Many people who have medical conditions that place them at high risk don’t know it.
- Even if we could infect a large number of low-risk people reasonably safely, the population does not mix evenly. High-risk individuals (particularly the elderly) are more likely to interact with other high-risk individuals. The disease would still be able to spread through those groups.
He thinks there are “legitimate reasons that we might need to consider something like a herd-immunity strategy”, but adds that the “people who are advocating it should acknowledge that it cannot be done without significant deaths”.
Won’t someone think of the economy?!
The lockdown is unfortunately exacerbating the economic pain of the virus, with one of the worst global recessions in modern history now all but certain.
This has prompted some to consider whether the medicine may be more damaging than the ailment — and indeed many will no doubt suffer as unemployment spikes.
The right-wing Institute of Public Affairs think tank called for an to end the lockdown two weeks ago, and believes the government “risks creating a much bigger economic and humanitarian crisis than that caused by the virus itself.”
This line of thinking has also led to some noteworthy opinion pieces, including an article in the Financial Review arguing many older Australians would be willing to die to protect the jobs of their children and grandchildren.
And in the United States, the president has for several weeks been pushing to re-open the economy, even as the virus remains out of control.
But the economy and health cannot be separated, says University of Melbourne Professor of Economics Chris Edmond.
“There is no possibility of the economy recovering to something that looks like normal without the virus under, effectively, high-level control.”
There are a couple of reasons why the economy cannot operate with a pandemic burning through it.
“One is that people will voluntarily themselves not participate in lots of activities they might otherwise,” Edmond says.
“The other is that as the virus rages, even people who are exposed and recover will be out of the labour force, they’ll be sick, in some cases they’ll have long-term medical complications. And that’s not even talking about the people that die.”
Economists are uncharacteristically in consensus on this point, he adds.
The only debate is around whether to start opening up once you’ve reached very few cases, or wait for total elimination, which could take far longer — or may never occur.
If there are only 10 new cases per day, is it worth still preventing most hospitality and retail staff earning an income? Or should we wait until new cases are down to three per day? Or zero? It’s hard to say.
With maybe 10% of the economy directly shut down — including people who aren’t able to go to work without violating social distancing rules, for example — and another large proportion indirectly reduced, this is an important distinction.
Thankfully, government spending is able to prop up a lot of this activity in the short-term. Public debt should not be a problem as long as the crisis does not drag on for years, he says.
Determining which parts of the economy to re-open first will require weighing the disease risk against potential economic returns, Edmond explains. Contentious debates are currently occurring within the bureaucracy about this.
“They should be thinking about what activities can you really not do? There are a whole bunch of activities you can do mostly from home, like my work, so I don’t need to come back anytime soon. There are lots of activities where that is true, and lots where it’s not.
“Of the ones you can’t do from home, so it’s costly for them to be shut down, some are really risky from a social mixing point of view — you think of restaurants, concerts, plays.”
At the very top of the reopening list should be activities that will help the medical system, he suggests.
“There are also other things that can’t be done from home but aren’t that risky. Some small businesses … they’d have the highest return — there’s not a good alternative to doing it from home, but also they’re low risk.”
This article is part of the Mandarin Premium’s special COVID-19 Road to Recovery series.
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