Covid-19 & Australia: Lucky Country?

Currently (at time of writing) in Australia, life is relatively ‘covid free’. Restaurants and shops are open, sports are being played, and even without limits on crowd numbers in some states. Yes, just over 100 people have died, but the last death now seems a long time ago. Not quite the success of a star like, Taiwan, but still a relatively positive outcome. There is a phrase made famous by a book of the same name: Australia, the lucky country and Covid-19 so far makes the tag seem correct.

This post reviews the ‘luck’ so far, as at June 2020, and challenge ahead.

That ‘luck’ will now face a new challenge, most of Australia completely exiting lockdown while still being able to ‘suppress’ small outbreaks as they emerge. Australia provides and interesting test case for the practically of completely lifting social distancing.

Covid-19 in Austrlalia:

Covid-19 Politics in Australia

Structure: National Vs State Governments

At the national level, the party in power, despite being called the ‘Liberal Party’, is home to views more conservative than the Conservative Party in the United Kingdom, seems to be heavily influenced by climate change deniers, and can seem at times as right wing as Trump Republicans.

While the above description may sound like a Brazil/USA/Russia style recipe for disaster when dealing with a science based issue such as dealing with a Covid-19 outbreak. But those extreme conservative voices are not the only voices within the national government, nor are such voices as vocal at state government level, and health which plays a significant role in dealing with Covid-19, is largely a state issue.

How Did Australia Eradicate ‘Community Spread’?

At the national level, the policy has never been eradication, as this would provide no immunity.

He [Brendan Murphy, National Chief Medical Officer] said that was one of the options available but the issue was “then you don’t have any immunity in the population and you really have to control your borders in a very aggressive way and that might be for a long time.”

Scott Morrison indicates ‘eliminating’ COVID-19 would come at too high a cost

Originally, the national government even wanted to avoid any lockdowns, with a ‘containment’ strategy that focused slowing the growth in the rate of infections. In the first months of the pandemic there were various signals that seemed to suggest ‘containment’ actually had a goal of slowly achieving herd immunity.

As it became evident that lockdowns would be required, national strategy changed from ‘containment’ to ‘suppression’. Lockdowns would now be used to reduce case numbers until cases were below ‘acceptable’, but not publically discussed, limit.

Despite this, all Australian states, with the possible exception of Victoria, effectively achieved eradication of new infections. At the time of writing, Victoria has some cases of community spread, but in all other areas of Australia, all cases detected recently, are people who were infected elsewhere, and the infection was detected on arrival or in quarantine after arrival.

The message has been confusing, with several strategies consistent with trying to expose lowest risk groups to infection, such as:

  • insisting schools remain open and students attend school
  • subsidising day care centres to provide free day care for all

But despite these signals, and a national goal of ‘eradication is not the policy’, eradication was effectively achieved.

The outcome resulted from the state governments:

  • effectively closing schools even when requested not to at the national level
  • imposing lockdowns beyond those promoted at the national level
  • aggressively tracking and tracing cases
  • community transmission never reaching significant numbers

In essence, despite the national government declaring a policy of ‘suppression’, the states have followed policies that allowed for eradication.

Normally, such divergent policies would create confusion and dissention, however the national government has worked on a consensus basis, and as there are many states and one national government, consensus meant compromise that maintained unity. Schools effectively moved to online learning, but in allowing supervision of children of essential services workers, could be said to remain ‘open’. Policies that delivered eradication became described as ‘suppression’. The national government skilfully placated the hard right with labels, while allowing the following of science by the states.

The national policy choices, together with key advisors promoting herd immunity as a strategy early in the pandemic, and together with statements from the prime minister that ‘it was important to achieve a level of immunity’, were all consistent with a government prepared for a far larger number of cases than the less than 10,000 cases and just over 100 deaths that have been seen since as at early July 2020.

But the actual policy implemented resulted in the surprising result of effective eradication. National policy was even rebranded ‘suppression’ to reflect new goals beyond ‘containment’. But was it all luck?

Luck?

Italy showed the world how dangerous Covid-19 could be. The outbreak in Wuhan preceded that in northern Italy, but there was always fears that ‘things were different in China’, or information on what was taking place in China was not transparent. When the west saw what has happening in Italy, the risk became very real.

The national government in Australia had a policy or containment, and it quickly became clear radical step are required to contain covid-19 outbreaks. The states in Australia introduced lockdowns beyond, and sometimes even in conflict with that national government.

It soon became clear that while without lockdowns cases kept growing exponentially, with lockdowns cases numbers not only stop growing, case numbers fall. Unlike in 1918, lockdowns do not just flatten the curve, but they can stop the curve. There was a period where the national government was pushing to ease restrictions while the states continued on the basis of caution. End result, without originally targeting eradication, Australia was soon basically there. Australia and New Zealand arrived at eradication by around the same time. New Zealand deliberately and with the plan to stay at that level. Australia by accident.

By the time cases were starting to fall in Italy, case in Australia were heading towards eradication. It turned out lockdowns were more effective than hoped. Australia with a policy of ‘containment’ was achieving similar results to neighbouring New Zealand who had set out to achieve eradication. With the benefit of hindsight, perhaps New Zealand went harder than required, but the big difference may prove to be the mindset of a desire to eradicate, in constrast to a mindset where eradication is seen has having gone further than necessary.

Australia achieving near eradication was a lucky success that, at least at a national government level, was beyond the desired level of success.

Australia: Containment, Suppression or Eradication?

What is ‘containment’?

The national government initially declared a policy of ‘containment’.

While no exact definition was given, the policy of ‘containment’ seemed to be to prevent case numbers rising, or at least limit the rise of cases. Initial steps to limit spread were introduced in phases as case numbers rose. Waiting until target levels of infection in the community before further limiting the spread. Containment was all around living with a level of infections and deaths for a period of around 6 months. Why six months? Well this pattern matched previous experience back in 1918, when only 0.3% of the population died, largely because keeping the case rate low avoided overwhelming the medical system. Mortality for covid-19 was at the time predicted at around the same percentage as 1918, which would have meant around 75,000 deaths in 2020, but the pandemic being over in around 6 months.

The goal of containment in the simplest form was to introduce measures to ‘contain’ case numbers with a band as described in this earlier post, without the government revealing the upper and lower bounds.

Suppression?

By early April, the government changed policy to ‘suppression’.

This policy reflected that under lockdown, cases fall. Instead of finding a level of lockdown to maintain cases within the required band, lockdowns would be introduced when cases are too high and reduced when cases fall to ‘acceptable’ levels. Again, the government did not communicate the high or acceptable levels driving the policy.

What exactly is ‘suppression‘? Cynically, ‘sometimes eradication may be achieved, but restrictions need not so strict as to achieve eradication’ or even to mean ‘lockdowns lifted as soon as politically acceptable’. Plus, if cases rise, wait until the public are scared before responding. Is that correct?

By definition suppression is to stop something by force, or to keep it from being known. But there is a specific use for outbreaks as discussed above, what is missing are the ‘bounds’.

Moving from the cynical and trying to discern from a more positive interpretation of political ‘spin’, in effect suppression means ‘there will be minor local outbreaks, and when there are, the proven lockdown approach will be applied locally to suppress each lockdown’. Just, again, without committing to case numbers would be a ‘suppression’.

Eradication.

Depending on who you listen to, eradication means either:

  1. take all steps to prevent any cases within national borders
  2. ensure all steps are taken to eliminate any community transmission of the virus

Generally, critics and advocates of ‘suppression’ declare eradication means #1, and state eradication is impractical, advocates declare eradication is #2 and has been achieved in most of Australia already.

End Of Luck? Why?

So why might Australia, having achieved almost eradication almost by luck, be in danger or not even achieving the less optimistic ‘suppression’?

Well, here are the risk factors:

  • With zero community spread, social distancing and other measures are not constantly being tested for effectiveness in preventing a rise in cases as happens in countries with a small but continuous number of new infections
  • Complacency in the community increases when there are no cases
  • The level of removing restrictions (spectators at sports, larger gatherings) during a period of zero community spread require massive changes to prevent spread when there is an outbreak
  • The efficacy of localised lockdowns is unproven
  • reversing a trajectory of rising cases is more difficult than maintaining cases at a constant level
    • will those in local lockdowns respond well to more strict quarantines than in place in countries with constant case levels

All these combined means the first significant cluster could produce a significant challenge.

Having achieve near eradication, while not even seeking eradication, the stage is set for complacency. Plus a background where Europe seems to be holding Covi-19 cases from rising further, while having continous level of background cases much higher case levels than in Australia. This seems to have created a political view that ‘we can wait until cases rise significantly before suppressing outbreaks’. It seems to be a common misconception the outlook is determined by the number of cases, rather than the rate of spread. It seems to be overlooked that if Australia move to Europe like case number from almost eradication, that is a serious outbreak. As outbreaks have momentum, recoding Europe like levels before responding would mean that rising cases momentum would go even higher before any response become effective.

The Test: A First Outbreak Under ‘Suppression’.

In late June, the cases started to rise in the one state to perhaps not achieve effective eradication: Victoria. The national government declared that as the strategy was always suppression, not eradication, an outbreak was effectively ‘nothing to see here’. Outbreaks like this, ‘local clusters’ were to be expected as part of the trade off for the better economic outcome delivered through ‘suppression’.

As outlined in ‘End of Luck’ (above), with all other states having achieved effective eradication, and even Victoria almost achieving eradication, social distancing and other restrictions in all states have been relaxed to very close to eradication levels. No mask wearing, restaurants open, even spectators at sporting events. Society prepared for eradication being achieved or in reach, rather than the measures now required for ‘suppression’ of a potential outbreak.

This could be a useful litmus test how, or if, local outbreaks can be dealt with within a territory where, outside the area of the clusters, the threat appears to have been contained.

The Role of the Media: Sensation & Misleading

The media has always reported only two numbers each day:

  • total cases
  • deaths

Total Cases.

Total cases groups together very different types of cases to yield the largest and therefore most sensational number. While there is impact on Australia that travellers test positive on arrival or while in quarantine, those numbers are completely insignificant in comparison with cases as a result of community transmission. Simply giving a total of such very different numbers is very mislead.

In reality: the main concern is community transmission, which has been hidden inside the total number.

This means Australians having already heard of case numbers of 20 per day or more, may not be alarmed about hearing those same numbers again. The real situation is 20 per day cases that were infected outside Australia is a potential problem if not managed properly. In contrast, 20 cases per day of community transmission is an actual realised problem.

This means when the real problem is present, with the same numbers reported, the community may not be alarmed as they should.

Deaths.

Again, it is the sensational number. What is hidden is how many people are hospitalised. Plus how many people have long term health impacts. When we only report deaths, it can give a false sense that all who do not die are unaffected and, particularly with young people, false sense of invulnerability.

Outcome: Luck Ending?

It is just too early to tell if this early outbreak is the start of Australia suffering the same fate as most developed nations.

  • Can a local cluster be contained, and if so how?
  • If cases do grow, how long to change the mindset from ‘it seems over’ to ‘we must all work together to stop this’.
  • Will the goal of ‘suppression’ create too much complacecency with rising cases?
  • Has media reporting, which has reported only the most sensational number, the total of all cases included those infected while outside Australia, have desensitised people to the far greater significant of community spread cases?

It takes a very small number of cases to start an outbreak when restrictions are at levels consistent with eradication, as is currently the case. From case numbers at eradication levels, moving to even low levels by international comparison means significantly rising cases. The response needs to be swift.

With a climate where ‘all is normal, expect outbreaks, all that is required is suppression’ is being declared by the Prime Minister, it feels like cases will escalate until disaster levels before there is a new lockdown or sufficient measures to stop case numbers climbing in the second most populous state, Victoria.

While most states have closed borders to Victoria, NSW, the most populous state, has been adamant borders should remain open, and has kept the border with Victoria open. Rather than closing that border, NSW is pushing for opening borders.

This is the recipe for the two most populous states to repeat what happened in the early days of Covid-19 in Europe, and in climate where many feel ‘it is over, and we need to be opening up’.

In summary, one state needs to react now. That state has opens borders with another state, and between them, those two states have 55% of the population of Australia.

Stay Tuned!

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